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College  of  ^fjpstctans;  ano  burgeons; 


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A  TABULAR  HANDBOOK 


AUSCULTATION  AND  PERCUSSION. 


jfor  ^tuuentsf  ano  pedant*. 


HERBERT  C.  CLAPP,  A.M.,  M.D. 

INSTRUCTOR   IN   AUSCULTATION  AND   PERCUSSION  IN  THE  BOSTON  UNIVERSITY  SCHOOL  OF   MEDICIN1, 
AND  PHYSICIAN  TO  THE  HEART   AND  LUNGS   DEPARTMENT   OP  THE   COLLEGE  DISPENSARY. 


WITH  FOUR  PLATES. 


"  NolUm  esse  medicus  sine  auscultatione  et  ytercussione.'1'' 

CORVISART. 


BOSTON: 

HOUGHTON,  OSGOOD  AND   COMPANY. 

Cfje  Btoermfce  p«sg,  CambriUp. 

1879. 


Copyright,  1878, 
Br  HERBERT  C.  CLAPP. 


RIVERSIDE,  CAMBRIDGE: 

ELECTROTYPED    AND    PRINTED     BY 

H.  0.  HOUGHTON  AND   COMPANY. 


PREFACE. 


In  the  preparation  of  this  little  book,  I  have  con- 
sulted the  works  and  compared  the  views  of  many 
who  have  been  eminent  in  the  physical  exploration 
of  the  chest,  such  as  Laennec,  Avenbrugger,  Corvi- 
sart,  Piorry,  Skoda,  Barth  and  Roger,  Walshe,  Hope, 
Stokes,  Fuller,  Grisolle,  Bennett,  Latham,  Flint,  Bal- 
four, Hayden,  Ziemssen,  Fothergill,  and  Loomis,  and 
here  desire  in  a  general  way  to  acknowledge  my  in- 
debtedness to  them,  as  it  has  seemed  impossible  to  do 
so  in  the  text  in  each  instance. 

Since  the  illustrious  Laennec  discovered  the  art  of 
auscultation  in  1816,  very  many  investigations  have 
been  made  and  much  has  been  written  on  the  sub- 
ject. While  on  the  one  hand  it  is  perfectly  surpris- 
ing how  little  the  master  mind  of  Laennec  left  to  be 
done,  and  how  many  of  his  descriptions,  classifications, 
and  meanings  of  sounds  still  remain  unimproved  upon 
in  spite  of  sharp  criticism,  yet  on  the  other  hand,  as 
would  naturally  be  expected,  other  experimenters 
since  have  discovered  new  facts,  and  by  a  wider  ex- 
perience have  been  able  to  point  out  more  or  less 
error  here  and  there  in  the  works  of  the  father  of 
auscultation.  I  have  endeavored  to  give,  arranged  in 
tabular  form,  a  condensed  summary  of  the  most  au- 
thentic observations  down  to  the  present  time. 


IV  PREFACE. 

As  to  the  theories  of  the  mechanism  of  the  produc- 
tion of  some  of  the  sounds,  there  has  been  a  great 
deal  of  controversy,  in  which  Skoda  with  his  "  con- 
sonance "  and  "  tension  "  and  other  theories  has  taken 
quite  a  prominent  part.  Those  theories  have  been 
given  in  the  following  tables  which  seem  most  rational 
and  which  are  at  present  most  generally  accepted. 

In  the  nomenclature  of  the  physical  signs,  care  has 
been  taken  not  to  use  those  terms  which  merely  ex- 
press somebody's  theory  of  their  mode  of  production. 
Skoda's  "  consonating  rale,"  for  instance,  is  a  very 
ill-advised  term,  as  the  theory  of  consonance  is  far 
from  being  universally  accepted,  and  no  one  who  re- 
jects the  theory  would  like  to  use  such  a  term. 
Even  the  common  term  "  mucous  rale "  has  been 
made  to  give  place  to  the  much  more  expressive 
"  bubbling  rale,"  which  does  not  imply  that  it  is 
always  caused  by  mucus,  but  leaves  room  for  its  pro- 
duction sometimes  also  by  pus,  serum,  softened  tuber- 
cle, etc. 

To  avoid  confusion,  and  for  the  convenience  of 
those  who  may  have  become  familiar  with  some  par- 
ticular authority,  many  of  the  synonyms  have  been 
added  in  small  type  in  parentheses. 

In  determining  what  classification  to  follow,  it  has 
been  thought  desirable  to  avoid  the  excessive  and 
complicated  refinements  of  some  authors,  without,  on 
the  other  hand,  losing  sight  of  the  necessity  for  suffi- 
cient thoroughness. 

There  has  been  an  effort  to  make  the  arrangement 
of  material  in  the  following  tables  so  systematic,  that 
any  special  point  needing  investigation  can  be  imme- 
diately referred  to,  without  a  tedious  and  laborious 


PREFA  CE.  v 

search  through  many  pages  and  perhaps  many  vol- 
umes. The  condensed  tabular  arrangement  will  be 
found  especially  advantageous  also  in  differential  di- 
agnosis, as  it  brings  into  such  close  juxtaposition  in- 
formation which  is  usually  widely  scattered,  rendering 
comparison  easy,  point  by  point. 

Studied  in  connection  with  Chapter  IV.  of  Da 
Costa's  excellent  work  on  Diagnosis,  with  its  graphic 
descriptions  and  convenient,  helpful  diagrams,  these 
tables  will  probably  furnish  the  student  with  all  that 
is  really  necessary  in  the  majority  of  cases  coming 
under  observation.  If,  however,  he  desires  to  make 
a  special  study  of  the  subject,  he  is  referred  to  the 
two  large  and  valuable  treatises  on  the  "Diseases 
of  the  Respiratory  Organs"  and  "Diseases  of  the 
Heart,"  written  by  Dr.  Austin  Flint  of  New  York, 
who  is  probably  the  greatest  authority  on  the  phys- 
ical diagnosis  of  such  diseases  in  this  country,  and  to 
whom  I  desire  to  acknowledge  myself  especially  in- 
debted. It  should  be  remembered,  however,  that  the 
pathology  of  these  works  is  not  quite  up  to  date. 

It  is  also  hoped  that  this  handbook  may  be  found 
useful  by  physicians  in  active  practice.  It  is  hardly 
to  be  expected  that  practitioners  who  do  not  make  a 
specialty  of  lung  and  heart  diseases,  even  if  they 
have  at  some  time  carefully  studied  into  the  subject, 
and  have  been  well  posted,  can  retain  in  their  memories 
for  immediate  use  at  all  times  every  point  necessary 
for  a  delicate  physical  diagnosis.  If  the  case  be  at 
all  obscure,  they  feel  the  necessity  of  consulting  some 
authority.  In  such  emergencies,  the  busy  doctor  may 
appreciate  such  a  time  and  labor  saving  contrivance 
as  the  present.  It  often  needs  only  a  word  here  and 
there  to  revive  memories  of  extensive  reading. 


vi  PREFACE. 

It  is  very  doubtful  if  at  this  late  day  any  well  edu- 
cated physician  could  be  found  to  despise  the  value 
of  auscultation  and  percussion  as  aids  to  diagnosis. 
Such  a  contempt  would  at  once  stamp  the  man  who 
showed  it  as  an  ignorant  pretender.  But  there  are 
many  who  do  not  feel  thoroughly  at  home  in  this 
branch,  and  on  account  of  too  slight  practical  ac- 
quaintance with  it,  and  lack  of  time  or  inclination 
for  a  laborious  research  into  its  theory,  prefer  to  trust 
for  the  most  part  to  the  symptoms  alone  rather  than 
to  the  uncertainties  (to  them)  of  physical  signs. 
Here  most  truly  "  a  little  knowledge  is  a  dangerous 
thing."  For  if  the  practitioner,  finding  jerking  res- 
piration, for  example,  in  a  given  case,  knows  that 
jerking  respiration  is  a  sign  of  phthisis,  and  does  not 
remember  that  it  may  be  a  sign  of  several  other  dis- 
eases, too,  and  on  the  strength  of  this  sign  alone  diag- 
nosticates the  case  as  phthisis,  it  would,  indeed,  be  far 
better  for  him  to  have  known  nothing  whatever  of 
auscultation  and  percussion,  and  to  have  been  guided 
entirely  by  the  symptoms.  It  is  such  partial  knowl- 
edge, to  say  nothing  of  the  utter  ignorance  of  others, 
that  has  to  some  extent  brought  auscultation  and  per- 
cussion into  disrepute  in  certain  places. 

It  is  very  desirable  to  have  a  proper  appreciation 
of  the  comparative  value  of  physical  signs  and  symp- 
toms, without  enthusiastically  overestimating  either. 
He  who  trusts  to  symptoms  alone  for  his  diagnosis  of 
heart  and  lung  diseases  will  very,  very  often  be  led 
astray.  On  the  other  hand,  the  mistake  may  be  made 
in  the  opposite  direction  of  placing  too  exclusive  reli- 
ance on  physical  signs  alone.  In  fact,  they  must  be 
taken  together  and  complement  eachj)ther.     If  they 


PREFACE.  vii 

are,  and  proper  attention  is  paid  to  the  history  of 
each  case,  and  also  to  its  well-known  pathological 
laws,  an  accurate  diagnosis  can  be  made  in  the  great 
majority  of  instances. 

When  speaking  of  heart  diseases,  Da  Costa  says  : 
"  A  knowledge  of  the  physical  signs  is  the  solid 
foundation,  without  which  any  structure  that  may  be 
reared  will  soon  tumble  to  pieces." 

In  fact,  the  symptoms  of  heart  disease  are  compara- 
tively insignificant.  Quite  so  much  cannot  be  said  of 
the  comparative  value  of  signs  and  symptoms  in  lung 
diseases ;  but  even  here  the  great  importance  of  the 
former  is  attested  by  the  immense  strides  which  have 
been  made  in  the  diagnosis  of  such  affections  since 
the  discovery  of  the  present  methods  of  physical  ex- 
ploration, which  would  have  been  utterly  impossible 
before. 

The  plates  have  been  reproduced  (with  slight  alter- 
ations), by  the  "  direct  transfer "  process,  from  the 
"  Handbuch  und  Atlas  der  topographischen  Percus- 
sion," by   Professor    Weil    of  Heidelberg,   published 

at  Leipzig  in  1877. 

H.  C.  CLAPP. 

544  Teemont  Street,  Boston,  October  3,  1878. 


CONTENTS. 


— ♦— 

PAGE 

INTRODUCTION xi 

PART  I. 

TABLE  NO.  1. 

Respiration  in  Health. 

Vesicular,  puerile,  senile,  and  tracheal  or  laryngeal  ....        20 

TABLE  NO.  2. 

Respiration  in  Disease.  (1.)  Abnormal  Intensity. 

Exaggerated,  feeble,  and  suppressed 22 

TABLE  NO.  3. 

Respiration  in  Disease.  (2.)  Abnormal  Rhythm. 

Jerking  respiration  and  prolonged  expiration 24 

TABLE  NO.  4. 

Respiration  in  Disease.  (3.)  Abnormal  Quality  and  Pitch. 

Bronchial,  broncho-vesicular,  cavernous,  and  amphoric    ....        26 

TABLE  NO.  5. 

Rales. 

I.  Tracheal  and  laryngeal ;  dry  and  moist 30 

II.  Bronchial ;  dry  (sonorous  and  sibilant),  and  moist  (coarse  and  fine 

bubbling  and  subcrepitant) 30 

III.  Vesicular ;  crepitant 34 

IV.  Cavernous ;  gurgling 34 

TABLE  NO.  6. 

Morbid  Pleural  Sounds. 

Friction  sounds,  metallic  tinkling,  and  splashing 36 


X  CONTENTS. 

TABLE  NO.  7. 

The  Voice  in  Health. 

Tracheal  or  laryngeal  voice  and  whisper,  normal  thoracic  vocal  reso- 
nance and  fremitus,  and  normal  bronchial  whisper  ....        40 

TABLE  NO.  8. 

The  Voice  in  Disease. 

Suppressed,  diminished,  and  increased  vocal  resonance  and  fremitus,  in- 
creased bronchial  whisper,  bronchophony  and  whispering  bron- 
chophony, cavernous  whisper,  amphoric  voice  and  whisper,  pec- 
toriloquy and  whispering  pectoriloquy,  segophony,  and  metallic  tink- 
iing 42 

TABLE  NO.  9. 

Percussion  Signs. 

Normal  vesicular  resonance,  flatness,  dullness,  and  tympanitic,  exag- 
gerated, amphoric,  and  cracked-metal  resonance       ....        46 

PART  II. 

TABLE  NO.  10. 

The  Physical  Diagnosis  op  Diseases  op  the  Lungs. 

Acute  and  chronic  pleurisy,  empyema,  hydrothorax,  pulmonary  oedema, 
pneumo-hydrothorax,  pneumothorax,  emphysema,  asthma,  bron- 
chitis, capillary  bronchitis,  plastic  bronchitis,  croupous  pneumonia, 
catarrhal  pneumonia,  chronic  pneumonia,  acute  miliary  tuberculo- 
sis, phthisis,  dilatation  of  bronchi,  carcinoma  of  lung,  and  intratho- 
racic tumors,  especially  aneurism 54 

TABLE  NO.  11. 

The  Physical  Diagnosis  of  Diseases  of  the  Heart. 

The  healthy  heart,  pericarditis,  endocarditis,  hypertrophy  of  the  left  and 
right  hearts,  dilatation,  valvular  lesions  of  the  left  heart  (aortic  ob- 
struction and  regurgitation,  and  mitral  obstruction  and  regurgita- 
tion), and  of  the  right  heart  (pulmonic  obstruction  and  regurgita- 
tion, and  tricuspid  obstruction  and  regurgitation),  fatty  degenera- 
tion, and  cardiac  neuroses 78 


INTRODUCTION. 


Pathognomonic  physical  signs  are  exceedingly 
rare.  It  is  not  true  that  each  disease  has  belonging 
to  it  one  or  more  individual  signs  like  labels,  which 
are  always  associated  with  it  and  no  other.  The  no- 
menclature of  diseases  is  not  so  rigidly  prescribed  by 
nature  as  it  would  be  in  such  a  case.  Physical  signs, 
instead  of  representing  individual  diseases,  represent 
merely  physical  conditions  which  may  be  common  to 
several  diseases.  For  instance,  dullness  on  percus- 
sion, bronchial  or  broncho-vesicular  respiration,  bron- 
chophony, and  increased  vocal  fremitus  in  combina- 
tion would  indicate  solidification  of  the  lung,  but 
they  clo  not  tell  us  on  what  the  solidification  depends. 
It  may  be  pneumonia,  it  may  be  phthisis,  it  may  be 
collapse  of  pulmonary  lobules,  it  may  be  lung  tissue 
compressed  by  a  pleuritic  exudation.  The  disease, 
the  particular  cause  of  the  solidification,  we  have  to 
reason  out  from  the  presence  or  absence  of  other 
physical  signs,  from  our  knowledge  of  pathology,  and 
from  the  history  and  symptoms  of  the  case. 

Before  beginning  the  study  of  auscultation  and  per- 
cussion, the  student  should  be  thoroughly  posted  in 
the  anatomy  and  physiology  of  the  organs  of  respira- 
tion and  circulation.  Then  naturally  follows  the  to- 
pography of  these  organs.     As  an  aid  in  constantly 


Xll  INTRODUCTION. 

keeping  before  the  mind  this  topography,  which  is  of 
very  great  importance,  especially  in  the  diagnosis  of 
heart  diseases,  the  plates  have  been  added  to  this  vol- 
ume, and  should  be  carefully  studied  and  often  re- 
ferred to.  The  details  of  pictorial  illustrations  are 
easier  for  most  persons  to  remember  than  long  verbal 
descriptions,  no  matter  how  accurate  they  may  be. 

For  convenience  in  localizing,  recording,  and  com- 
paring signs,  the  surface  of  the  chest  has  been  mapped 
out  into  anterior,  lateral,  and  posterior  regions,  right 
and  left,  as  follows  :  — 

Anteriorly  —  The  supra-clavicular  region,  extend- 
ing from  the  clavicle  upwards  a  distance  varying  from 
half  an  inch  to  an  inch  and  a  half;  clavicular,  the 
space  occupied  by  the  clavicle  ;  infra-clavicular,  be- 
tween the  clavicle  and  the  third  rib  ;  mammary,  be- 
tween the  third  and  sixth  ribs;  infra-mammary,  be- 
low the  sixth  rib ;  supra-sternal,  the  hollow  space 
above  the  sternum ;  superior-sternal,  under  the  ster- 
num above  the  third  rib  ;  inferior -sternal,  under  the 
sternum  below  the  third  rib. 

Laterally  —  The  axillary  region,  having  for  its 
lower  boundary  a  horizontal  extension  of  the  lower 
boundary  of  the  mammary  region  ;  infra-axillary,  be- 
low this  line. 

Posteriorly  —  The  scapular  region,  the  space  oc- 
cupied by  the  scapula,  extending  also  to  a  horizontal 
line  drawn  through  its  lower  angle ;  infra-scapular, 
below  this  line  to  the  twelfth  rib  ;  inter- scapular,  be- 
tween the  inner  margin  of  the  scapula  and  the  spinal 
column. 

It  is  very  essential  that  the  healthy  sounds  of  aus- 
cultation and  percussion  should  become  thoroughly 


INTRODUCTION.  xiii 

familiar  to  the  student  before  he  spends  much  time 
on  the  morbid  sounds.  And  yet,  there  is  a  constant 
tendency  to  hurry  over  and  neglect  the  former  for 
the  sake  of  getting  at  the  practical  work  of  the  lat- 
ter. No  one  would  undertake  to  tune  a  piano  without 
being  so  familiar  with  the  true  tones  that  he  could 
recognize  the  least  departure  from  them.  Very  often 
in  the  most  important  cases  brought  to  the  physician, 
where  there  is  the  greatest  desire  for  information,  as, 
for  example,  in  the  detection  of  the  very  beginnings 
of  phthisis,  the  deviations  from  the  normal  sounds  are 
so  slight  as  to  be  entirely  disregarded  by  those  who 
do  not  know  by  practice  exactly  what  the  normal 
sounds  in  the  different  regions  of  the  chest  ought  to 
be.  And  even  where  one  thinks  he  knows  this,  con- 
stant reference  to  the  healthy  standard  is  necessary. 

Auscultation  is  said  to  be  immediate  when  the  un- 
assisted ear  is  applied  to  the  chest  of  the  patient,  and 
mediate  when  a  stethoscope  is  used.  Both  methods 
are  in  use,  and  it  is  very  desirable  to  become  practi- 
cally familiar  with  each.  Some  physicians  think  that 
they  can  hear  as  well  with  the  unassisted  ear  as  with 
the  stethoscope  ;  but  the  great  majority  of  those  who 
have  much  to  do  with  auscultation  give  a  very  de- 
cided preference  to  that  instrument.  Those  who  have 
used  a  stethoscope  for  any  considerable  length  of 
time  very  seldom  like  to  give  it  up.  It  is  often  pref- 
erable on  grounds  .of  delicacy  when  examining  lady 
patients,  and  the  avoidance  of  too  close  contact  which 
it  insures  is  certainly  pleasanter  to  the  examiner, 
when  the  patient  happens  to  be  at  all  uncleanly. 
Besides,  it  can  be  applied  to  certain  places  (such  as 
the  hollow  over  the  clavicle,  for  instance)  to  which  it 


xiv  INTRODUCTION. 

is  difficult  or  impossible  to  adjust  the  ear.  With  it, 
also,  particular  sounds,  which  we  may  wish  to  locate 
definitely  and  to  hear  as  far  as  possible  unmixed  with 
others  (as,  for  instance,  valvular  murmurs),  can  be 
circumscribed.  With  Oammanns  double  or  binaural 
stethoscope,  which  is  the  best,  the  sounds  are  intensi- 
fied and  made  more  distinct,  and  some  are  rendered 
audible  which  would  be  inappreciable  to  the  unassisted 
ear.  At  first,  until  one  gets  accustomed  to  it  and 
learns  how  to  use  it,  there  is  a  disagreeable  humming 
or  buzzing  which  is  very  confusing,  but  this  soon 
passes  off.  The  pectoral  extremity  should  be  closely 
applied  with  moderate  pressure,  and  the  edges  should 
fit  the  skin  exactly  all  around,  not  being  tilted  up  at 
one  side  to  allow  the  air  to  enter.  The  room  should 
be  quiet  and  there  should  be  no  friction  between  the 
stethoscope  and  the  clothing.  Stiff  hair  on  the  chest 
under  the  instrument  often  occasions  a  sound  which 
might  be  confused  with  the  crepitant  rale.  Beginners 
almost  always  get  the  ear-pieces  in  the  wrong  way. 
They  should  follow  the  direction  of  the  auditory  canal. 
The  stethoscope  should  be  applied  to  the  bare  skin. 
When  the  unassisted  ear  is  used,  it  is  pleasanter  to 
have  over  the  chest  one  thickness  of  soft  cloth,  like 
the  undergarment,  or  a  towel.  When  an  accurate  ex- 
amination in  a  doubtful  case  is  desired,  it  is  utterly 
impossible  to  make  it  without  removing  the  most,  if 
not  all,  of  the  clothing  from  the  chest ;  and  the  man 
who,  in  such  a  case,  gives  two  or  three  raps,  puts  his 
head  down  over  a  stiffly  starched  shirt  or  creaking 
corsets  or  rustling  silk,  and  then  solemnly  and  oracu- 
larly pronounces  an  opinion,  is  generally  acting  igno- 
rantly  or  dishonestly  by  his  patient.     It  might  almost 


INTRODUCTION.  xv 

be  said  that  if  the  intra-thoracic  noises  are  all  so  loud 
that  they  can  be  heard  above  the  noise  which  the 
outside  clothing  makes,  it  is  not  of  very  much  im- 
portance to  the  diagnosis  that  they  be  heard  at  all, 
for  in  such  conditions  the  symptoms  are  generally 
enough.  The  great  danger  in  listening  through  all 
the  clothing  is  that  of  not  hearing  (or  mixing  up)  deli- 
cate and  important  signs.  In  many  cases,  where  the 
problem  is  to  decide  whether  or  not  phthisis  is  pres- 
ent, it  is  sufficient  to  unbutton  the  upper  part  of  the 
clothing  and  turn  it  aside  so  as  to  expose  the  infra- 
clavicular regions  for  examination,  as  phthisis  gener- 
ally attacks  these  regions  first.  But  even  here,  if  no 
deposit  be  found,  particular  thoroughness  demands  a 
further  search. 

In  immediate  auscultation  it  is  advisable  to  close 
one  ear  with  the  finger  to  exclude  outside  noises, 
and  particularly  when  studying  vocal  phenomena.  In 
the  latter  case,  besides,  the  patient  should  turn  his 
head  to  one  side  and  put  his  hand  up  to  his  mouth  to 
prevent  the  auscultator's  confusing  his  voice  com- 
ing directly  from  the  mouth  with  the  vocal  resonance 
coming  through  the  chest.  The  auscultator  should 
also  avoid  stooping  over  too  much  when  listening,  as 
the  congestion  of  blood  caused  by  such  a  position 
dulls  somewhat  the  acuteness  of  hearing.  Unless  too 
weak,  the  patient  is  best  examined  in  the  sitting  post- 
ure, with  his  arms  hanging  down  for  the  anterior 
portion  of  the  chest,  raised  and  crossed  over  his  head 
for  the  lateral  regions,  and  crossed  with  the  body  bent 
forwards  for  the  posterior  regious.  Generally  he  has 
to  be  instructed  to  breathe  harder  than  usual,  and  often 
has  to  be  shown  how  to  breathe  properly.    In  children 


xvi  INTRODUCTION. 

it  is  easy  to  judge  of  the  vocal  resonance  when  they 
cry.  Finally,  one  side  of  the  chest  should  be  con- 
stantly compared  with  the  other,  portion  by  portion. 

Percussion,  as  a  method  of  diagnosticating  disease, 
was  discovered  by  Avenbrugger,  whose  researches 
were  published  at  Vienna  in  1761.  They  attracted 
but  little  attention,  however,  until  Corvisart  fifty 
years  afterwards  translated  them  into  French  and  in- 
troduced the  practice  into  the  French  hospitals.  Per- 
cussion, like  auscultation,  is  both  immediate  and  medi- 
ate. The  immediate  (which  was  the  only  method 
known  to  Avenbrugger  and  Laennec),  where  the  chest 
was  struck  directly  by  the  fingers,  is  now  never  re- 
sorted to,  having  been  entirely  superseded  by  the 
invention  by  Piorry  of  mediate  percussion,  which 
interposes  some  solid  substance,  called  a  pleximeter, 
between  the  chest  and  the  percussing  agent.  For 
this  purpose,  little  plates  of  ivory  or  wood  with  han- 
dles have  been  used,  or  a  flat  piece  of  common  elastic 
India  rubber.  The  best  pleximeter,  however,  is  a 
tapering  cylinder  of  hard  rubber  or  gutta-percha 
about  two  inches  long,  flanging  at  each  end,  one  cir- 
cular end-piece  being  smaller  than  the  other  for  ap- 
plication to  the  intercostal  spaces  and  supra-clavicular 
regions,  the  body  of  the  cylinder  (which  is  applied 
to  the  chest  at  right  angles)  making  an  excellent 
handle.  The  best  percussor  is  a  little  hammer  with 
a  hard  rubber  rod  or  handle  which  can  be  detached 
from  the  head,  which  is  made  of  brass  and  tipped 
with  soft  rubber.  Most  physicians  use  for  a  plexime- 
ter the  left  middle  or  forefinger,  with  its  palmar  sur- 
face applied  to  the  chest,  and  for  a  percussor  the  right 
middle  or  forefinger  (or  both  together),  bent  so  as  to 


INTRODUCTION.  xvn 

strike  at  a  right  angle.  Although  it  takes  considera- 
ble time  and  practice  to  become  really  expert  in  per- 
cussing with  the  fingers,  much  more  than  with  the 
instruments  just  described,  yet  everybody  should 
learn  this  method,  as  it  is  a  very  valuable  one,  and 
the  instruments  cannot  always  be  at  hand  to  be  de- 
pended upon.  Where  one  has  a  great  deal  of  per- 
cussing to  do,  however,  he  generally  prefers  the  in- 
struments, as  so  much  pounding  on  the  back  of  the 
finger  used  as  a  pleximeter  is  apt  to  make  it  sore. 
Besides,  the  instruments  bring  out  the  sounds  more 
distinctly,  especially  for  purposes  of  demonstration  to 
others. 

Unless  the  patient  is  really  obliged  to  lie  down,  he 
should  be  percussed  in  the  sitting  or  standing  posture, 
with  his  arms  placed  as  already  described  for  aus- 
cultation, the  examiner  being  directly  in  front.  The 
two  sides  should  be  percussed  at  the  same  stage  of 
respiration,  as  the  expanded  lung  occupies  more  room, 
pushing  down  the  liver  and  spleen  and  pressing  more 
in  front  of  the  heart ;  the  difference  between  a  full 
inspiration  and  a  deep  expiration  being  very  consid- 
erable. 

Since  we  draw  our  inferences  as  to  the  condition 
of  the  lungs  from  the  comparative  sound  in  differ- 
ent parts  of  the  chest  rather  than  from  the  absolute 
sound,  this  varying  somewhat  in  different  individu- 
als, it  is  important  to  strike,  immediately  after  each 
other  and  with  the  same  force,  portions  on  one  side 
which  correspond  as  nearly  as  possible  to  portions 
on  the  other  side.  Four  or  five  raps  in  succession 
are  best,  and  should  be  quick  and  sharp  rather  than 
slow  and  heavy.     More  forcible  blows  are  required  to 


xvm  INTRODUCTION. 

elicit  the  sounds  of  deeply  seated  than  of  superficial 
portions.  The  finger  or  pleximeter  should  be  applied 
firmly  on  the  spot  to  be  examined,  and  with  precisely 
the  same  amount  of  firmness  on  the  corresponding 
spot  on  the  other  side. 

The  pressure  should  be  sufficient  to  condense  the 
soft  parts  on  the  outside  of  the  chest.  Percussion 
should  be  performed  by  a  movement  of  the  wrist 
alone,  the  arm  and  forearm  remaining  motionless.  It 
would  be  well  for  the  beginner  to  commence  by  per- 
cussing the  right  infra-clavicular  region  in  a  healthy 
subject,  and  to  contrast  the  vesicular  resonance  found 
here  with  the  flatness  of  the  liver.  Next  he  might 
try  to  bring  out  the  proper  sound  of  that  part  of  the 
liver  which  lies  underneath  the  lung.  After  becoming 
practically  familiar  with  all  the  sounds  in  the  different 
regions  in  health,  he  can  try,  as  a  final  test  of  his 
powers,  the  deep  cardiac  space.  If  he  can  bring  out 
the  sounds  of  that  satisfactorily,  he  may  consider  him- 
self proficient. 

Heart-sounds. — In  health  there  is  no  difficulty  in 
telling  by  auscultation  which  is  the  first  and  which 
the  second  sound  of  the  heart  by  the  rhythm  and 
the  distinctive  characters  of  the  two  sounds  at  the 
apex  and  base  ;  and  generally  it  is  easy  to  decide  the 
question  in  the  same  way  if  the  heart  is  diseased, 
when  it  is  desired  to  know  whether  a  murmur  is  sys- 
tolic, presystolic,  or  diastolic.  But  sometimes  it  is 
impossible  or  difficult  to  do  so.  In  such  cases,  if  the 
apex-beat  can  be  felt,  this  being  synchronous  with  the 
first  sound,  the  problem  is  at  once  solved.  If  it  can- 
not be  felt,  the  radial  pulse  will  settle  the  point,  or 
still  better  the  carotid,  which  is  more  nearly  synchro- 
nous with  the  first  sound  of  the  heart. 


xJX&Ajl   J. 


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PAET  I. 

PHYSICAL  SIGNS. 


20 


AUSCULTATION   AND  PERCUSSION. 


TABLE  NO.  1. 


VARIETIES. 

CHARACTER  OF  THE   SOUND. 

Vesicular  Respiration. 
(Pulmonary.) 

Inspiration. 

A  soft,  diffused  sound  of  a  breezy  character,  grad- 
ually developed  and  continuous.    Increased  in  in- 
tensity with  the  rapidity  and  force  of  respiration, 
and  prolonged  by  a  full  inspiration.    Low  pitch. 

Expiration. 

Not   vesicular,  but  feebly   blowing   in   quality. 
Pitch  lower  and  intensity  much  less  than  in  inspi- 
ration.    Usually  not  more  than  one  fourth  the 
length  of  inspiration,  and  absent  in   about  one 
third  of  the  cases.     No  interval  between  inspira- 
tion and  expiration. 

Puerile  Respiration. 

The  same  quality,  pitch,  and  rhythm  as  the  (pul- 
monary) vesicular  murmur,  but  exaggerated  or 
intensified  in  degree. 

Senile  Respiration. 

The  same  as  the  vesicular  respiration,  except 
that  the  intensity  is  diminished  and  the  expiration 
relatively  more  developed  and  longer. 

Tracheal  or  Laryngeal 
Respiration. 

Inspiration. 

Tubular  in  quality,  loud,  dry,  and  hollow. 

High  pitch.    An  interval  between  inspiration 
and  expiration. 

Expiration. 

Tubular  in  quality.    Uniformly  present.    As 
long   as   the   inspiratory   sound,    and  generally 
longer.    More  intense  and  higher  in  pitch. 

AUSCULTATION  AND  PERCUSSION. 


21 


RESPIRATION   IX  HEALTH. 


HOW  PRODUCED. 


Inspiratory  Sound. 

1.  "By  vibrations  excited  in  the  in- 
ward current  of  air  by  its  friction 
against  the  walls  of  the  air  passages. 

2.  By  the  obstacles  presented  by  the 
subdivision  of  the  bronchi ;  "  and 

3.  By  the  forcible  separation  of  the 
walls  of  the  pulmonary  vesicles,  which 
after  the  previous  expiration  have  be- 
come more  or  less  adherent  on  account 
of  their  natural  moisture. 

Expiratory  Sound. 

Simply  "  by  the  vibrations  excited  in 
the  expired  air  by  its  friction  against 
the  walls  of  the  air-passages." 


The  greater  intensity  of  the  murmur 
is  owing  to  the  greater  freedom  of  the 
action  of  the  lungs  in  early  childhood. 


The  change  is  owing  to  the  attenua- 
tion of  the  walls  of  the  air-cells  in  aged 
persons. 


By  the  rush  of  air  through  a  tube  of 
considerable  diameter,  rough  and  irreg- 
ular on  its  internal  surface,  and  possess- 
ing sound-reflecting  properties.  "  The 
higher  pitch  of  the  expiratory  sound  is 
due  to  the  greater  contraction  of  the 
glottis  by  the  approximation  of  the  vo- 
cal chords  in  expiration." 


USUAL   SEAT. 


All  parts  of  the  chest.  There  are 
variations  in  the  intensity  of  the  mur- 
mur in  the  different  regions  of  the  chest, 
there  being  more  in  the  infra-clavicular 
and  inter-scapular  and  in  the  axillary 
and  infra-axillary  regions  than  in  the 
mammary  and  infra-mammary  regions, 
and  least  of  all  in  the  scapular  region. 

Sometimes  there  is  r.lso  a  slight  disparity  be- 
tween the  two  sides,  in  which  case  the  vesicu- 
lar quality  is  more  marked  and  the  pitch  lower 
on  the  left  than  on  the  right  side,  in  the  latter 
there  being  a  slight  approach  to  the  character 
of  broncho-vesicular  respiration  (Table  No. 
4),  i.  e.,  expiration  a  little  longer  with  higher 
pitch,  and  inspiration  a  little  shortened. 


In  children,  in  all  parts  of  the  chest 
where  the  ordinary  vesicular  respira- 
tion is  audible. 


In  old  age,  in  all  parts  of  the  chest 
where  the  ordinary  vesicular  respira- 
tion is  audible. 


In  the  supra-sternal  region,  over  the 
trachea  and  larynx. 


22 


AUSCULTATION  AND  PERCUSSION 


TABLE  NO.  2.—  RESPIRATION  IN  DISEASE. 


Exaggerated  Res- 
piration. 

(Puerile,  supplementary, 

increased,  hypervesicu- 

lar.) 


CHARACTER  OF  THE  SOUND. 


Feeble  Respira- 
tion. 

(Diminished,  weak.) 


Suppressed  Respi- 
ration. 

(Absent.) 


Like  the  healthy  vesic- 
ular murmur  in  pitch, 
rhythm,  and  quality,  but 
intensified  in  degree.  Iden- 
tical in  character  with  the 
puerile  respiration  of 
healthy  children. 


"  The  ordinary  vesicular 
murmur,  not  altered  in 
character,  but  simply  di- 
minished in  intensity  and  du- 
ration." 


No  sound  is  heard. 


HOW  PRODUCED. 


By  the  excessive  action 
of  certain  healthy  portions 
of  the  lungs,  set  up  to  sup- 
ply the  deficiency  of  res- 
piration in  other  portions, 
which  are  destroyed  or 
affected  by  disease. 


By  any  cause  which  in- 
terferes with  and  prevents 
the  full  inflation  of  the 
lungs.     Such  as  — 

1.  An  obstruction  to  the 
passage  of  air  in  some  por- 
tion of  the  air  tubes. 

2.  An  obstruction  or 
over -distention  of  the  air 
vesicles. 

3.  Some  restraint  on 
the  movements  of  the 
chest. 

4.  The  respiratory  mur- 
mur may  be  imperfectly 
transmitted  to  the  ear, 
owing  to  intervening  fluids, 
solids,  or  air. 


By  very  great  obstruc- 
tion to  the  entrance  of  air, 
or  by  the  interposition  of 
fluid  or  air  in  the  cavity 
of  the  pleura,  preventing 
the  transmission  of  the 
sound. 


AUSCULTATION  AND  PERCUSSION. 


23 


ABNORMAL   INTENSITY. 


USUAL  SEAT. 


Not  peculiar  to  any  portion  of  the 
chest,  and  not  diffused  generally 
throughout  both  sides  of  the  chest,  like 
the  healthy  puerile  breathing,  but 
limited  to  certain  spots  in  the  vicinity 
of  diseased  portions  of  the  lungs,  or 
heard  all  over  the  healthy  lung,  when  the 
other  is  diseased.  If  heard  all  over 
both  lungs,  it  is  to  be  regarded  merely 
as  an  individual  peculiarity  and  not 
as  a  sign  of  disease. 


Variable.  The  whole  or  a  part  of  a 
lung. 

Feeble  respiration,  occurring  in  so 
many  conditions,  becomes  of  diagnos- 
tic importance  only  when  associated 
with  other  phenomena. 


"  May  occur  in  any  portion  of  the 
chest,  but  always  limited  to  one  or  more 
parts,  and  usually  to  the  whole  or  some 
portion  of  one  lung  only." 


DISEASES   INDICATED. 


Pleurisy. 

Pneumonia. 

Phthisis. 

Vesicular  emphysema. 

Apoplectic  effusion. 
Carcinoma. 
Spasmodic  asthma. 
Pneumothorax. 
Foreign  body  in  bronchus. 
Aneurismal  or  other  intra -thoracic  tumors 
pressing  on  certain  bronchi. 


1.  Croup  ;  oedema  or  spasm  of  the  glottis  ; 
inflammatory  exudations  in  the  larynx  ;  for- 
eign body  in  a  bronchus;  mucus,  serum,  blood, 
or  pus  in  bronchus  ;  swelling  of  mucous  mem- 
brane in  bronchitis  ;  asthma  ;  permanent  con- 
traction of  bronchi ;  tumors  pressing  on  bron- 
chi, i.  e.,  aneurism  or  enlarged  lymphatic 
gland. 

2.  Phthisis,  pneumonia,  pulmonary  oede- 
ma, vesicular  emphysema,  extravasation  of 
blood. 

3.  Paralysis  of  costal  muscles  or  of  dia- 
phragm ;  general  debility ;  permanent  contrac- 
tion after  chronic  pleurisy  ;  old  pleuritic  ad- 
hesions ;  deformity  of  chest ;  the  pain  of  acute 
pleurisy,  pneumonia,  intercostal  neuralgia, 
pleurodynia,  or  peritonitis  :  the  mechanical 
interference  of  ascites,  pregnancy,  and  abdom- 
inal tumors. 

4.  Pleuritic  effusion,  thick  layer  of  lymph 
on  pleura,  hydrothorax,  pneumo-hydrotho- 
rax,  tumors,  thick  layer  of  fat  on  outside  of 
chest. 


Same  diseases  as  feeble  respiration, 
with  this  difference,  that  it  indicates 
more  decided  anatomical  lesions.  Most 
commonly  observed  in  connection  with 
excessive  effusions  of  fluid  or  air  in  the 
pleura. 


24 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  3.  —  RESPIRATION  IN  DISEASE. 


VARIETIES. 

character  of  the  sound. 

HOW    PRODUCED. 

Jerking 
Respiration. 

(Interrupted,  wavy, 
cogged- wheel.) 

Both    sounds,    especially 
the  inspiratory,  instead   of 
being  even  and  continuous 
from    their  commencement 
to   their   close,   are  broken 
into  one,  two,  or  more  parts. 

1.  By  some  local  obstacle 
to  the  ingress  or  egress  of  air. 
Usually  the  pressure  of  tu- 
bercular or  other  deposit,  or 
the  presence  of  thick  mucus 
in  the  air  passages,  or  spasm 
of  a  tube. 

2.  By  nervousness  or  shrink- 
ing on  account  of  pain. 

Prolonged 
Expiration. 

The  rhythm  changed  so 
that  the  expiration  is  length- 
ened   absolutely   and    rela- 
tively   to     the    inspiration, 
which    is    generally   short- 
ened. 

1.  When  the  air-cells  are 
over-distended  and  have  lost 
their  natural  elasticity  from 
this  distention  or  (2)  on  ac- 
count of  deposits  in  their 
walls,  the  air  has  difficulty  in 
making  its  escape.  This  dif- 
ficulty may  be  increased  in 
the  latter  case  by  the  promi- 
nences produced  by  the  de- 
posit on  the  interior  of  the 
final  bronchial  ramifications, 
these  prominences  opposing 
obstacles  to  the  rapid  egress 
of  air. 

AUSCULTATION  AND  PERCUSSION. 


25 


ABNORMAL  RHYTHM. 


USUAL  SEAT. 

DISEASES   INDICATED. 

1.  Limited   to   a  part  of  the  chest, 
usually  one  of  the  apices,  where  it  is 
of  more  clinical  significance  than  when 

2.  Generally  diffused  over  the  chest. 

1.  Incipient  phthisis. 
Circumscribed  bronchitis. 
Asthma. 

2.  Nervousness. 
Pleurisy. 
Pleurodynia. 
Intercostal  neuralgia. 

This  sound  is  occasionally  observed  even 
in  healthy  persons. 

1.  All  over  one  or  both  sides  of  the 
chest,  especially  the  upper  parts. 

2.  In  the  infra-clavicular  region,  es- 
pecially on  the  left  side. 

1.  Emphysema 

(if  non-tubular  and  of  low  pitch). 

2.  Phthisis 

(if  tubular  and  of  high  pitch). 

Occasionally  heard  to  a  slight  extent  on 
the  right  side  of  the  healthy  chest. 

26 


AUSCULTATION  AND  PERCUSSION. 


TABLE    NO.    4.  —  RESPIRATION    IN    DISEASE. 


VARIETIES. 

CHARACTER  OF  THE    SOUND. 

HOW   PRODUCED. 

Bronchial 
Respiration. 

(Tubular.) 

Inspiration. 

Quality     tubular,    non- 
vesicular.   Intensity  vari- 
able, pitch  high.     Inspi- 
ratory sound   shortened ; 
ends  before  end  of  inspi- 
ratory act.      Rarely  ab- 
sent.   Can  be  imitated  by 
blowing  through   a  tube 
formed  by  the  fingers  and 
palm  of  one  hand. 

Expiration. 

Quality  tubular.     Pro- 
longed;    as    long    as    or 
longer  than  the  sound  of 
inspiration  and  more  in- 
tense.    Pitch  still  higher. 
Rarely  absent. 

It  always  denotes  consid- 
erable or  complete  solidifica- 
tion of  pulmonary  substance, 
either  by  the  addition  of 
some  morbid  material  or  by 
compression.  This  involves 
suppression  of  the  vesicular 
murmur.  The  sound  pro- 
duced by  the  passage  of  air 
through  the  bronchi,  which 
in  health  is  stifled  by  the 
vesicular  murmur  and  ren- 
dered inaudible,  is  now  trans- 
mitted to  the  ear  intensified 
by  the  solidified  lung,  which 
is  a  better  sound-conductor 
than  the  healthy  lung. 

Broncho-vesicu- 
lar  Respiration. 

(.Rude,  rough,  harsh, 

vesiculobronchial,  tu- 

bulo-vesicular.) 

Inspiration. 

The  tubular  and  vesic- 
ular quality  combined  in 
varied   proportions,    and 
the  pitch  raised  in  pro- 
portion to  the  amount  of 
tubular    quality.      Dura- 
tion frequently  shortened 
at  the  end.    Intensity  va- 
riable.      Sometimes    ab- 
sent. 

Expiration. 

Prolonged.      Generally 
more  intense  than  inspi- 
ration. Pitch  higher  than 
in  inspiration.      Quality 
according  to  quality  in  in- 
spiration.  Sometimes  ab- 
sent. 

Being  a  combination,  in 
varied  proportions,  of  the 
bronchial  and  vesicular  res- 
piration, it  is  produced  by 
the  same  cause  as  the  pre- 
ceding, although  not  to  the 
same  extent ;  the  amount  of 
solidification  not  being  suf- 
ficient to  extinguish  all  vesic- 
ular murmur. 

AUSCULTATION  AND  PERCUSSION. 


27 


ABNORMAL  QUALITY  AND  PITCH. 


USUAL    SEAT. 


In  phthisis  and  pleurisy  generally 
in  the  upper  part  of  the  chest.  In 
pneumonia  generally  the  lower  part 
behind,  especially  on  the  right  side. 
In  other  cases  variable. 

Being  identical  with  the  healthy  "  Tracheal 
Respiration,"  it  may  be  studied  in  the  supra- 
sternal region  of  a  sound  person. 


Same  as  the  preceding.  A  very 
important  sign  in  the  diagnosis  of  in- 
cipient phthisis. 


DISEASES   INDICATED. 


Pneumonia. 
Phthisis. 
Pleuritic  effusion. 

Collapse  of  pulmonary  lobules. 

Pulmonary  oedema. 

Pulmonary  apoplexy. 

Carcinoma. 

Hydrothorax. 

Hy  dro  -perica  rdium . 

Aneurism  and  other  tumors. 


Same  diseases  as  the  preceding, 
only  indicating  a  lesser  amount  of  solid- 
ification. In  the  resolution  of  acute 
lobar  pneumonia  (croupous),  all  vari- 
eties of  the  sound  may  be  heard  by 
daily  auscultation,  from  that  which 
verges  on  the  bronchial  in  complete 
solidification,  to  that  which  verges  on 
the  vesicular,  which  comes  with  re- 
covery. 


28 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  4,  Continued.  —  RESPIRATION  IN  DISEASE. 


VARIETIES. 

CHARACTER  OF  THE  SOUND. 

HOW  PRODUCED. 

Cavernous 
Respiration. 

Inspiration. 

Quality  blowing  simply ; 
non-vesicular,    non-tubu- 
lar.     Often   mixed   with 
gurgling.    (Table  No.  5.) 

Expiration. 

Quality  blowing.  Low- 
er pitch  than  inspiration. 
May   be    absent.      Often 
mixed  with  gurgling. 

Some  recognize  also  a  bron- 
cho-cavernous     respiration, 
which,  as  its  name   signifies, 
is    a  combination    in    varied 
proportions    of  this  and   the 
bronchial  respiration. 

Produced  by  the  passage 
of  air  into  and  from  a  cav- 
ity with  flaccid  walls. 

Absent  when  the  cavity  is 
filled  with  liquid,  or  when 
the  tubes  leading  to  it  are 
obstructed.  If  deep-seated, 
and  beneath  solidified  lung, 
it  may  be  drowned  out  by  the 
loud  bronchial  respiration. 
Rales  also  may  obscure  it. 

It  can  be  imitated  by  blow- 
ing into  a  cavity  formed  by 
the  two  hands. 

Amphoric 
Respiration. 

A  kind  of  musical  in- 
tonation  like    the   sound 
produced      by      blowing 
upon  the  open  mouth  of 
a  decanter  or  phial.     It 
may    accompany     either 
inspiration  or  expiration 
or  both.    It  may  be  hum- 
ming and  of  low  pitch  or 
decidedly     ringing     and 
metallic. 

Not  caused,  like  cavernous 
respiration, "  by  the  free  circu- 
lation of  air  within  a  cavity, 
but  by  the  current  of  air  in 
the  bronchial  tubes  acting 
upon  the  air  contained  within 
a  cavity."  The  cavity  must 
have  more  or  less  rigid  walls, 
which  do  not  collapse  with 
expiration;  it  must  be  of 
considerable  size,  partially  or 
entirely  free  from  liquid  con- 
tents ;  there  must  be  an  un- 
obstructed communication 
(or  merely  a  very  thin  sep- 
tum) between  a  bronchial 
tube  and  the  cavity,  and  the 
perforation  must  be  above 
the  level  of  the  liquid,  if 
there  be  any  liquid. 

AUSCULTATION  AND  PERCUSSION. 


29 


ABNORMAL  QUALITY  AND  PITCH,  Continued. 


USUAL  SEAT. 


Heard  over  a  circumscribed  area, 
corresponding  to  the  size  of  the  cavity. 

Being  vastly  more  common  in 
phthisis  than  in  other  diseases,  its 
seat  is  generally  at  the  summit  of  the 
chest. 


Generally  confined  to  a  circum- 
scribed space,  but  is  sometimes  dif- 
fused more  or  less  over  the  chest. 


DISEASES   INDICATED. 


Phthisis. 

Rarely  in 
Pulmonary  abscess. 
Gangrene. 
Cancer. 
Bronchial  dilatation. 


Almost  pathognomonic  of  pneu- 
mo-hydrothorax  with  pulmonary  fis- 
tula.    Sometimes  in  phthisis. 

Still  more  rarely  in  abscess,  etc. 


30 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  5. 


VARIETIES. 

character  of  the  sound. 

relation  to  inspiration 
and  expiration. 

Whistling,  wheezing,  crow- 

Mostly with    inspiration. 

I.  Tracheal 

ing,    whooping,   etc.      Most 

Sometimes  with  both. 

AND 

of  them  are  heard  without 

Laryngeal 

special  auscultation  and  at  a 

Rales. 

distance. 

a.  Dry  or  vibrat- 

ing. 

Bubbling     sounds,     often 

With  both. 

b.  Moist  or  bub- 

called "  death-rattles." 

bling. 

Low-pitched,  musical  sounds, 

With  both  or  either,  es- 

compared to  snoring,  cooing, 

pecially  with  expiration. 

II.  Bronchial 

buzzing,  grunting,  humming, 

Rales. 

a  note  of  a  bass-viol,  etc. 

a.  Dry  or  vibrat-' 

mg. 

(1.)  Sonorous 

Rales. 

High-pitched,      whistling, 

With  both   or  either,   es- 

hissing, or  clicking  sounds  of 

pecially  with  inspiration. 

variable  intensity  and  dura- 

tion   and    irregular    recur- 

rence.     Often  compared  to 

(2.)  Sibilant 

shrill  musical  tones,  the  cries 

Rales. 

of  young  animals,  the  chirp- 
ing   of    birds,   whistling    of 
wind  through  a  keyhole,  etc. 
Heard  with  the  respiratory 
murmur,  or  the  latter  may 
be  masked.    Loudest  in  asth- 
ma. 

AUSCULTATION  AND  PERCUSSION. 


31 


RALES  (Rhonchi). 


HOW  PRODUCED. 


1.  By  contraction  at 
the  glottis  from  spasm, 
oedema,  exudation  of 
lymph,  etc. 

2.  By  diminution  of 
calibre  of  tube  below  the 
glottis. 


By  the  passage  of  air 
through  mucus  or  other 
liquid  in  the  tube. 


"  By  the  vibrations  ex- 
cited by  the  passage  of 
air  through  the  larger 
bronchi,  irregularly  nar- 
rowed, either  hy  spas- 
modic contraction  of  their 
circular  fibres,"  or  by 
swelling  of  their  mucous 
membrane,  or  by  the  ad- 
hesion of  viscid  mucus  to 
their  walls,  or  by  the 
pressure  of  a  tumor. 


Produced  in  the  same 
manner,  but  in  the  smaller 
bronchial  tubes. 


USUAL  SEAT. 


Larynx  and  trachea. 
These  sounds  are  often 
propagated  through  the 
bronchial  tubes  and 
heard  in  the  chest,  where 
they  may,  in  a  few  cases, 
be  thought  to  originate. 
Auscultation  of  the 
larynx  and  trachea  will 
at  once  settle  the  point. 


Larynx  and  trachea. 


Constantly  liable  to 
change  position.  May 
sometimes  disappear  af- 
ter coughing.  They  are 
either  — 

1 .  More  or  less  diffused 
over  the  whole  chest ;  or, 

2.  Confined  to  one  side 
of  the  chest,  or  limited 
to  a  circumscribed  space. 
(In  phthisis  the  circum- 
scribed space  is  gener- 
ally at  the  summit  of  the 
chest.) 


Same  as  sonorous 
rales,  with  which  they 
are  frequently  mingled. 


DISEASES   INDICATED. 


Laryngismus     stridu- 
lus. 
Pertussis. 
Croup. 

Pressure  of  a  tumor. 

Morbid  growths  or  depos- 
its. 

Cicatrization  of  ulcers. 

Paralysis  of  laryngeal 
muscles. 


The  moribund  state. 

Coma. 

Inability  to  expectorate. 


1.  Asthma. 
Bronchitis. 

2.  Circumscribed  bron- 
chitis occurring  with 
pneumonia  or  phthisis. 


Same  diseases  as  the 
sonorous  rales,  and  indi- 
cating that  the  smaller 
tubes  are  affected. 


32  AUSCULTATION  AND  PERCUSSION. 

TABLE   NO.  5,   Continued. 


VAKIETIES. 

character  of  the  sound. 

RELATION    TO    INSPIRATION 
AND   EXPIRATION. 

b.  Moist  or  bub- 
bling. 

(1.)  Coarse  Bub- 
bling Rales. 

(Coarse  mucous 
rales. ) 

A  coarse  bubbling  sound, 
conveying  the  impression  of 
the  bursting   of   bubbles  of 
somewhat    large   size.     The 
"death-rattles"  are   an   ex- 
aggerated type  of  them.    If 
any  solidification  of  the  lung 
exists  around   the  tubes  in 
which  the  sound  is  produced, 
the  pitch  is  raised  in  propor- 
tion to  the  amount. 

With  either  or  both. 

(2.)  Fine  Bub- 
bling Rales. 

(Fine  mucous  rales.) 

The  same  quality  of  sound, 
but  the  bubbles  are  smaller. 
The    coarse    and  fine  bub- 
bling rales  may  be  imitated 
by  blowing  into  a  tumbler 
of  water   through  different 
sized  tubes. 

With  either  or  both. 

(3.)    SuBCREPI- 

tant  Rales. 

The  same  quality,  but  the 
bubbles   are  very  small  in- 
deed.    Still,  they  are  some- 
what unequal  in  size,  as  in 
the     other      moist       rales. 
Slowly  evolved. 

With  either  or  both. 
When    with    inspiration, 
near  the  beginning. 

AUSCULTATION  AND  PERCUSSION.  33 

RALES,  Continued. 


HOW   PRODUCED. 

USUAL   SEAT. 

DISEASES    INDICATED. 

By  the  bubbling  of  air 
through    liquid    (mucus, 
pus,     softened     tubercle, 
blood,  or  serum),  in  the 
larger      bronchial      tubes. 
Bubbling      rales,      both 
coarse  and  fine,  are  very 
often  called  mucous  rales. 
This   term  is  not  so  ap- 
propriate,  as   the   liquid 
by  means  of  which  they 
are  produced  is  not  al- 
ways    mucus.        Unless 
specified,  when  "bubbling 
rales "     are     mentioned, 
bronchial    and    not    tra- 
cheal are  understood. 

Constantly    liable    to 
change     position,    espe- 
cially   after    expectora- 
tion   or   coughing,    and 
not  occurring  with  every 
respiration. 

They  are  either  — 

1.  More   or  less    dif- 
fused   over    the   whole 
chest,  especially  the  in- 
fra-scapular regions,  or 

2.  Confined  to  one  side 
of  the  chest,  or  limited 
to  a  circumscribed  space. 
(In  phthisis  the  circum- 
scribed space  is  generally 
the  summit  of  the  chest.) 

1.  Bronchitis. 

2.  Circumscribed  bron- 
chitis,    occurring     with 
phthisis  or  pneumonia. 

Softened  tubercle,  etc., 
in  tubes  in  phthisis,  blood 
in  haemoptysis  or  pulmo- 
nary apoplexy,  serum  in 
cedema,   pus    in    pulmo- 
nary or  hepatic  abscess. 

Produced  in  the  same 
manner    in    the    smaller 
bronchial  tubes. 

Same  as  coarse  bub- 
bling rales,  with  which 
they  are  frequently  min- 
gled. 

Same  as  coarse  bub- 
bling rales,  but  smaller 
tubes  affected. 

Produced  in  the  same 
manner  in  the  very  mi- 
nute   bronchial    ramifica- 
tions. 

Same  as  coarse  bub- 
bling    rales,     excepting 
that  they  are  very  much 
less  liable  to  change  po- 
sition. 

1 .  Capillary  bronchitis. 
Pulmonary  cedema. 

2.  Lobar      pneumonia 
during  resolution. 

Incipient  phthisis. 

34  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  5,  Continued. 


RELATION    TO   INSPIRATION 

VARIETIES. 

CHARACTER  OF  THE   SOUND. 

AND   EXPIRATION. 

Fine,   dry,  crepitating   or 

With  inspiration  exclusively, 

crackling  sounds,  compared  to 

and  near  the  end  of  it,  es- 

those produced  by  tine  salt 

pecially  in    forced    inspira- 

III. Vesicular 

on  a  fire,  or  by  rubbing  a 

tion. 

Kales. 

lock    of    hair    between    the 
thumb  and   finger   close  to 
the  ear.     They  resemble  the 

Crepitant 

subcrepitant,     from     which 

i 

Rales. 

they  must  be  distinguished. 
The  crepitations  are  equal  in 
size,  dry,  not  bubbling,  con- 
stant,  not    variable,   rapidly 
evolved,    not    suspended    by 
coughing  and  expectoration, 
and  occur  only  with  inspira- 
tion. 

A  hollow,  gurgling  sound, 

With  either  or  both. 

often    very    intense,    some- 

Oftener   with    inspiration 

times  metallic  or  amphoric, 

than  expiration. 

IV.  Cavernous 

usually  of  low  pitch,  convey- 

Rales. 

ing   the   impression  of  very 
large    bubbles    bursting   in   a 
large  space,  the  loudness  of 

Gurgling 

the  gurgling  being  propor- 

Rales. 

tionate  to  the  size  of  the  cav- 
ity.    When    this    is    small, 
hardly  distinguishable  from 
coarse    bubbling    bronchial 
rales. 

AUSCULTATION  AND  PERCUSSION. 
RALES,  Continued. 


35 


HOW    PRODUCED. 


Produced,  according  to 
the  most  rational  theory 
(Dr.  Carr's),  by  the  abrupt 
separation,  during  inspi- 
ration, of  the  walls  of  the 
air-vesicles,  which  had, 
after  the  preceding  ex- 
piration, become  adherent 
by  means  of  the  viscid 
exudation  incident  to  the 
early  stage  of  inflamma- 
tion. 

This  mode  of  its  production 
can  be  illustrated  by  moisten- 
ing the  thumb  and  finger  with 
a  little  paste  or  solution  of 
gum  arabic,  and  alternately 
pressing  them  together  and 
separating  them  near  the  ear. 


Produced  by  the  burst- 
ing of  large  bubbles  and 
the  agitation  of  a  mass  of 
liquid  in  a  cavity  of  con- 
siderable size.  When  the 
cavity  is-  empty,  cavern- 
ous respiration  takes  the 
place  of  the  cavernous 
rales.  The  two  signs 
may  thus  confirm  each 
other.  Not  produced  if 
the  cavity  is  full.  The 
communication  with  the 
bronchial  tubes  must  be 
unobstructed  and  below 
the  level  of  the  liquid. 
Therefore  gurgling  is  not 
heard  in  every  case  of  a 
cavity. 


USUAL  SEAT. 


Most  commonly  over 
the  lower  part  of  the 
chest  behind,  on  one  side, 
oftener  the  right. 

Often  associated  with 
the  subcrepitant  rales  in 
the  resolution  of  pneu- 
monia. 


A  circumscribed  space, 
in  forty-nine  out  of  fifty 
cases  at  the  summit  of 
the  chest. 


DISEASES    INDICATED. 


Almost  pathognomonic 
of  pneumonia. 

If  heard  only  over  a 
circumscribed  space  at 
the  summit  of  the  chest, 
phthisis  is  generally  indi- 
cated. Even  in  such 
cases  the  crepitant  rale  is 
indicative  of  a  circum- 
scribed pneumonic  proc- 
ess. 


Phthisis. 

Cavity  from  abscess,  cir- 
cumscribed gangrene,  can- 
cer, etc. 


36 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.   6. 


Friction 
Sounds. 


Metallic  Tink- 
ling. 


CHARACTER  OF   THE   SOUND. 


Grazing,  rubbing,  creaking  like  new 
leather,  grating,  crumpling,  rasping, 
the  harshness  varying  according  to 
the  roughness  of  the  surface  of  the 
pleura. 

The  grazing  and  rubbing  sounds, 
which  are  the  most  common,  may  be 
imitated  by  placing  over  the  ear  the 
palm  of  one  hand  and  moving  over 
its  dorsal  surface  slowly  the  pulpy  por- 
tion of  a  finger  of  the  other  hand. 

Intensity  very  variable,  sometimes 
heard  even  by  the  patient.  The 
sound  is  dry  and  appears  to  be  near 
the  ear,  not  continuous  generally,  but 
jerking,  rhythmical  with  respiration. 
Transient  or  lasting.  Occasionally 
attended  with  fremitus. 


A  high-pitched,  abrupt,  short,  sil- 
very tone,  like  the  tinkling  of  a  small 
bell,  dropping  small  shot  into  a  brass 
basin,  etc.,  consisting  of  a  single 
sound,  or  more  commonly  of  two, 
three,  or  more  in  quick  succession. 
Accompanies  respiration,  speaking, 
and  coughing,  especially  the  two  lat- 
ter. Irregular  in  its  appearance. 
Only  liable  to  be  confounded  with  a 
somewhat  similar  sound  in  the  stom- 
ach. 


relation  to  inspi- 
ration AND  EX- 
PIRATION. 


"With  both  or  with 
inspiration  alone. 

Very  rarely  with 
expiration  alone. 


With  both  or 
either ;  especially 
at  the  end  of  inspi- 
ration. 


AUSCULTATION  AND  PERCUSSION. 


37 


MORBID   PLEURAL   SOUNDS. 


HOW  PRODUCED. 

USUAL  SEAT. 

DISEASES    INDI- 
CATED. 

By  the  rubbing    together  of   two 
pleural  surfaces  (pulmonary  with  cos- 
tal, and  often  diaphragmatic  with  cos- 
tal) which  have   been  roughened  by 
lymph  or  other  deposit. 

In   common 
pleurisy     usually 
confined  to  a 
small  space  at  the 
middle    or   lower 
part  of  the  chest 
laterally   or   pos- 
teriorly ;  but  may 
be    more   or  less 
diffused,  and  occa- 
sionally is  heard 
over    the    entire 
chest. 

In    phthisis   at 
the  summit  of  the 
chest. 

Pleurisy. 

Also  in  phthisis 
and  pneumonia 
where  there  is  ac- 
companying   sec- 
ondary pleurisy. 

There  must  be  a  large  cavity,  contain- 
ing liquid  and  air  or  gas,  and  almost 
invariably  there  is  communication  with 
a  bronchial  tube. 

There  are  several  different  theories 
as  to  the  production  of  this  sound,  and 
probably   each  one   of   the   following 
(which  have  all  been  experimentally 
verified)  may  account  for  it  either  alone 
or  in  connection  with  the  others. 

1 .  Drops  of  fluid  fall  from  the  upper 
part  of  the  space  upon  the  surface  of 
the   liquid   below,  when   the  patient, 
previously  lying  down,  sits  or  stands 
up.     (Laennec. ) 

2.  Air,  working  through  a  fistulous 
orifice  opening  below  the  level  of  the 
liquid,  rises  to  the  surface,  forming  bub- 
bles which   break    and    produce    the 
sound.     (Spittel.) 

3.  Simple  agitation  of  the  liquid  may 
give  rise  to  the  sound,  as  in  succussion, 
coughing,  etc. 

4.  Bubbles  of  mucus  bursting  at  the 
opening  of  a  fistulous  orifice  situated 
above  the  level  of  the  liquid. 

Generally  at  the 
middle     third    of 
the  chest,  in  front, 
behind,  or  at  the 
side. 

Sometimes  dif- 
fused    over    the 
entire     chest    on 
one  side. 

Sometimes  a 
circum  scribed 
space  at  the  sum- 
mit. 

Almost  pathog- 
nomonic of  pneu- 
mo-hydrothorax. 

Very  rarely  in 
phthisical  cavities. 

38 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  6,  Continued. 


VARIETIES. 


Splashing. 

(Hippocratic  succus- 
sion  sound.) 


CHARACTER  OF   THE   SOUND. 


Such  a  noise  as  is  produced  by 
shaking  a  bottle  partly  filled  with 
liquid. 

Only  liable  to  be  confounded  with  a 
somewhat  similar  sound  in  the  stom- 
ach. 

Often  it  has  a  high-pitched  am- 
phoric tone,  and  may  be  mingled  with 
metallic  tinkling.  Sometimes  loud 
enough  to  be  heard  at  a  distance. 


RELATION  TO  INSPI- 
RATION AND   EX- 
PIRATION. 


AUSCULTATION  AND  PERCUSSION. 


39 


MORBID   PLEURAL   SOUNDS,  Continued. 


HOW  PRODUCED. 


Produced  by  jerking  the  body  of  the 
patient  with  an  abrupt  forcible  move- 
ment, the  ear  being  in  contact  with  or 
in  close  proximity  to  the  chest. 

Sometimes  produced  unintentionally 
by  the  patient  himself,  by  quick  mo- 
tions, such  as  horseback  exercise, 
jumping,  etc. 

The  liquid  must  not  be  too  abun- 
dant nor  too  thick,  and  there  must 
also  be  air  in  the  cavity. 


USUAL   SEAT. 


Generally  over 
the  whole  of  the 
affected  side,  un- 
less there  are  ad- 
hesions. 

Very  rarely  at  the 
summit  of  the  chest. 


DISEASES  IN- 
DICATED. 


Pathognomonic 
of  pneumo-hydro- 
thorax. 

Very  rarely  in  tu- 
bercular and  other 
cavities  in  the  lung. 


40 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  7. 


VARIETIES. 


CHARACTER  OF    THE    SOUND. 


Tracheal  Voice. 

(Tracheophony,  laryn- 
geal voice,  laryngoph- 
ony.) 

A  strong  resonance,  with  a  powerful  sensation  of  con- 
cussion or  shock,  and  also  with  a  strong  sense  of  vibration 
or  thrill  called  fremitus,  which  can  be  appreciated  by  the 
ear  as  well  as  by  palpation.  The  voice  is  concentrated  and 
near  the  ear,  seeming  to  pass  right  through  the  stethoscope. 
Sometimes  the  articulated  words  are  transmitted  so  as  to 
be  heard  as  distinctly  as  when  coming  direct  from  the 
lips.  When  this  occurs  over  the  chest  as  a  result  of  dis- 
ease, it  is  called  perfect  pectoriloquy.  Oftener,  however, 
the  transmission  of  speech  from  the  trachea  furnishes  a 
type  of  imperfect  pectoriloquy.  All  these  phenomena 
may  differ  in  intensity.  The  variations  in  the  first  three, 
however,  —  resonance,  shock,  and  fremitus,  —  do  not  al- 
ways correspond  with  the  variations  in  the  distinctness 
with  which  speech  is  transmitted. 

Tracheal 
Whisper. 

(Whispering 
tracheophony.) 

There  is  little  or  no  shock  or  fremitus.  Whispered 
words  are  transmitted  more  or  less  perfectly,  more  so 
generally  than  loud  words  ;  this  feature  corresponding  to 
the  morbid  sign  called  whispering  pectoriloquy. 

Normal  Thoracic 

Vocal 

Kesonance. 

The  resonance  is  much  weaker  than  in  tracheophony, 
and  is  quite  variable  in  intensity.  Often  over  portions  of 
the  chest  none  is  appreciable,  and  in  some  persons  it  is 
absent  over  the  entire  chest.  The  sound  is  diffused  and 
seems  farther  removed  from  the  ear,  rarely  accompanied 
with  shock,  and  not  always  with  fremitus.  The  sound 
often  amounts  to  little  more  than  a  humming  or  buzzing. 
No  pectoriloquy. 

Normal 

Bronchial 

Whisper. 

The  characters  of  the  sounds  produced  by  the  whis- 
pered voice  are  identical  with  those  produced  by  the  act  of 
expiration,  in  all  respects  except  that  the  sounds  are  more 
intense,  generally,  than  those  even  of  a  forced  expira- 
tion. The  intensity  is  variable,  as  in  the  preceding. 
There  is  the  same  difference  between  this  and  the  tracheal 
whisper  with  regard  to  diffusion,  concentration,  and  near- 
ness to  the  ear  that  there  is  between  the  normal  thoracic 
vocal  resonance  and  the  tracheal  voice. 

AUSCULTATION  AND  PERCUSSION 
THE   VOICE   IN  HEALTH. 


41 


HOW    PRODUCED. 

USUAL  SEAT. 

The  resonance  by  the  reverberation 
of  the  voice  in   the   sound-reflecting 
tube,  the  shock  by  the  sudden  arrest 
of  the  column  of  expired  air  by  the 
act  of  speaking,  the  fremitus  by  the 
vibrations  of  the  tracheal  tube  in  con- 
nection with  those  of  the  vocal  chords, 
and  the  distinct  transmission  of  speech 
by  the  concentrating  and  sound-reflect- 
ing properties  of  the  hollow  tube. 

Trachea  and  larynx. 

Apply  the  stethoscope  over  the  broad  sur- 
face of  the  thyroid  cartilage  or  just  above 
the  sternal  notch.  To  bring  out  the  vocal 
phenomena  to  the  best  advantage,  both  here 
and  over  the  chest  in  health  and  in  disease, 
the  patient  should  be  instructed  to  count 
slowly  one,  two,  three,  one,  two,  three,  etc., 
at  first  with  the  loud  voice  and  afterwards  in 
a  whisper. 

The  sound  corresponds  to  the  sound 
of  expiration  in  tracheal  or  laryngeal 
respiration,  and  is   in  fact   identical 
with  it. 

Trachea  and  larynx. 

The  vibrations  are  weakened   and 
diffused  by  passing  through  the  sub- 
divisions   of    the    bronchi     and    the 
spongy  tissue  of  the  lung  before  reach- 
ing the  surface  of  the  chest. 

There  are  considerable  variations 
in  this  sound  in  the  different  regions 
of  the  chest,  it  being  more  intense  in 
the  infra-clavicular  and  inter-scapular 
regions  than  in  the  axillary  and  infra- 
axillary  ;  and  in  the  latter  more  than 
in  the  mammary  and  infra-mammary. 
There  is  the  least  resonance  in  the 
scapular  region. 

There  is  also  often  a  slight  difference  in 
the  two  sides  comparatively.  When  there  is 
any  difference,  the  right  side  is  the  more 
resonant.  This  last  remark  applies  also  to 
fremitus.  The  amount  of  the  fremitus,  how- 
ever, is  not  necessarily  proportionate  to  that 
of  the  resonance. 

The  conduction  of  sound  by   the 
whispered  voice  is  chiefly  by  the  air 
contained  in  the  bronchial  tubes. 

About  the  same  variations  are  ob- 
served as  in  the  preceding. 

42 


AUSCULTATION  AND  PERCUSSION. 


TABLE  NO.  8. 


VARIETIES. 

character  of  the  sound. 

Diminished  and  Sup- 
pressed Vocal 
Eesonance  and  Fre- 
mitus. 

Simply  less  in  intensity  than  normal,  or  absent 
altogether.  There  being  no  standard  of  intensity, 
comparison  must  be  made  between  the  two  sides, 
allowing,  of  course,  for  the  slight  possible  differ- 
ence in  health.     (Table  No.  7.) 

The  fremitus  generally,  but  not  always,  lessened 
in  the  same  proportion  as  the  resonance. 

Increased  Vocal 

Resonance  and 

Fremitus. 

Merely  an  increase  in  intensity,  without  change 
in  other  respects.  Generally  associated  with  the 
broncho-vesicular  respiration. 

Increased  Bronchial 
Whisper. 

Same  as  the  expiratory  sound  in  broncho-vesic- 
ular respiration,  namely,  increase  of  intensity  and 
length,  more  or  less  tubular  in  quality,  and  higher 
in  pitch  than  the  whisper  in  health,  these  altera- 
tions being  proportionate  to  the  degree  of  solid- 
ification. 

Bronchophony. 

Vocal  sound  concentrated  and  near  the  ear. 
Pitch  higher  than  normal.  Intensity  and  fremi- 
tus variable;  may  be  greater  or  less  than  in 
health. 

Whispering  Bron- 
chophony. 

Same  as  the  expiratory  sound  in  the  bronchial 
respiration,  namely,  intensified,  long,  high  pitched, 
and  tubular. 

AUSCULTATION  AND  PERCUSSION. 


43 


THE   VOICE   IN  DISEASE.    • 


HOW  PRODUCED. 


By  the  removal  of  the 
lungs  from  the  thoracic 
walls,  or  by  anything  that 
prevents  the  circulation  of 
the  column  of  air  in  the 
tubes  which  propagate  the 
sound. 


By  slight  consolidation  of 
the  lung  tissue  around  the 
air  tubes,  whereby  the 
sound-reflecting  power  of 
the  tubes  is  increased,  and 
the  pulmonary  parenchyma 
is  rendered  more  homoge- 
neous and  a  better  sound- 
conductor. 


Same  as  the  preceding. 


Same  as  the  preceding, 
except  that  the  solidijica- 
tion  is  greater,  and  some- 
times complete.  Less  solid- 
ification is  required  than 
for  the  production  of  bron- 
chial respiration.  There- 
fore bronchophony  may  be 
associated  with  a  broncho- 
vesicular  respiration  as 
well  as  with  bronchial. 


Same  as  the  preceding. 


USUAL  SEAT. 


When  the  pleural 
cavity  is  partially  filled 
with  fluid,  the  vocal 
resonance  and  fremitus 
are  diminished  or  sup- 
pressed below  the  level 
of  the  liquid,  but  in- 
creased generally  just 
above  the  level,  owing 
to  the  condensation. 


Not  confined  to  any 
part  of  the  chest,  but 
usually  most  marked 
and  of  the  greatest  sig- 
nificance towards  the 
apices  of  the  lungs  in 
phthisis. 


Same  as  the  preceding. 


In  pneumonia  gen- 
erally the  middle  and 
lower  thirds  behind. 

Of  great  importance 
as  suggestive  of  phthisis 
when  existing  at  the 
apex  of  the  lung. 

In  pleuritic  effusion, 
over  condensed  lung  at 
summit  of  chest. 


Same  as  the  preced- 


ing. 


DISEASES    INDICATED. 


Pleuritic  effusion,  em- 
pyema, hydrothorax, 
pneumo  -  hydrothorax, 
obstruction  of  bron- 
chial tubes  by  mucus  or 
by  the  pressure  of  aneu- 
rismal  or  other  tumors. 

Exceptional  in  solidifica- 
tion, but  sometimes  observed 
in  complete  solidification  of 
pneumonia,  abscess  full  of 
pus,  cavity  filled  with  liquid, 
pulmonary  oedema. 


Phthisis. 

Pneumonia. 

Compressed  lung  in 
moderate  pleuritic  ef- 
fusion and  collapse  of 
pulmonary  lobules. 

Carcinoma,  haemorrhagic 
infarctus.  Sometimes  over 
cavities. 


Same  as  the  preceding. 


Pneumonia. 
Phthisis. 

Lung  condensed  by  effu- 
sion in  pleurisy  or  pneumo- 
hydrothorax,  or  by  pressure 
of  a  tumor,  collapse  of 
pulmonary  lobules,  cancer, 
or  bronchial  dilatation,  the 
tubes  being  surrounded  by 
condensed  and  indurated 
lung. 


Same  as  the  preced- 
ing. 


44  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  8,  Continued. 


VARIETIES. 

character  of  the  sound. 

Cavernous  Whisper. 

Same  as  the  expiratory  sound  in  the  cavernous 
respiration,  namely  :  low  pitch  and  blowing  (non- 
tubular)  quality,  with  variable  intensity. 

Amphoric  Voice  and 
Whisper. 

A  ringing  sound  of  a  metallic  quality,  not  dis- 
tinctly articulated,  not  transmitted  forcibly 
through  the  stethoscope,  but  resembling  the 
sound  produced  by  speaking  into  an  empty  jar. 
The  amphoric  quality  may  accompany  the  loud 
voice  or  whisper,  more  especially  the  latter,  the 
resonance  and  fremitus  of  the  loud  voice  obscuring 
somewhat  the  musical  intonation. 

Pectoriloquy  and 
Whispering  Pecto- 
riloquy. 

Articulated  words  are  transmitted  directly  through 
the  stethoscope  into  the  ear.  This  is  more  fre- 
quent with  the  whispered  than  with  the  loud 
voice.  Care  must  be  taken  not  to  confuse  the 
words  coming  directly  from  the  patient's  mouth 
with  the  transmission  of  them  through  the  chest. 
Unless  a  double  stethoscope  is  used,  one  ear  must 
be  closed.  This  is  a  rare  sign,  but  the  type  of  it 
can  be  studied  in  health  in  connection  with 
tracheal  voice. 

^Egophony. 

A  tremulous,  bleating  or  quavering  sound,  like 
the  cry  of  a  goat,  from  which  the  term  is  derived, 
and  often  compared  to  the  "  Punch  and  Judy " 
voice.  Synchronous  with,  but  of  a  higher  pitch 
than,  the  voice  of  the  patient,  or  else  follow- 
ing it  like  a  feebly  whispered  echo,  and  rarely 
traversing  the  stethoscope. 

Metallic  Tinkling. 

Has  the  same  characters  when  heard  in  connec- 
tion with  the  loud  or  whispered  voice  as  with  res- 
piration (which  see),  but  is  more  intense. 

AUSCULTATION  AND  PERCUSSION. 
THE  VOICE  IN  DISEASE,  Continued. 


45 


HOW    PRODUCED. 

USUAL   SEAT. 

DISEASES  INDICATED. 

Produced     by     the    air 
passing  out  of   an  empty, 
superficial  cavity  with  flac- 
cid walls. 

A  circumscribed  space, 
generally  at  summit  of 
chest,  — 

Or  in  other  parts. 

Phthisis. 

Purulent,  gangrenous,  or 
cancerous  excavation. 

By  the  reverberation  of 
the  voice,  causing  an  echo, 
in  a  large  cavity  with  rigid 
walls,   and   subject  to   the 
same  conditions  as  in  the 
production     of     amphoric 
respiration  (which  see). 

Same    as    amphoric 
respiration. 

Same     as     amphoric 
respiration. 

"  Sometimes  by  the  con- 
densation   of    lung    tissue 
around   a  large  bronchus, 
whereby   the   transmission 
of  the  sound  to  the  ear  is 
facilitated.      More    gener- 
ally  by  the  formation  of 
cavities  possessing  smooth, 
sound-reflecting  walls." 

"  Not  confined  to  any 
portion  of    the   lungs, 
but     occurring      most 
commonly  at  the  apices 
and  in  the  upper  lobes." 

Chiefly  Phthisis. 

Sometimes    pneumonia, 
pouchlike  dilatation  of  bron- 
chi, circumscribed  gangrene, 
and  abscess. 

By  the  vibrations  conse- 
quent on  the  existence  of  a 
thin   stratum  of  liquid  in 
the  pleural  cavity. 

Not  apt  to  occur  when 
the  chest  is  more  than  half 
full   of  liquid.     The   lung 
must  be  more  or  less  con- 
densed at  the  level  of  the 
liquid.     This  accounts  for 
the     elevation     of     pitch. 
When  there   becomes  too 
much  liquid,  the  asgophony 
stops.     Therefore  in  acute 
pleurisy  it  rarely  continues 
longer  than  two   or  three 
days,  sometimes  only  for  a 
few  hours. 

Not  confined  to  any 
portion   of    the   chest, 
but  most  common  at  or 
near  the  inferior  angle 
of  the   scapula  ;    from 
here    often    extending 
to     the    inter-scapular 
space,   and,  in  a  zone 
from  one  to  three  fin- 
gers   broad,    following 
the  line  of  the  ribs  to- 
wards the  nipple   (the 
patient  sitting).     This 
line   indicates   not  the 
level  of  the  liquid,  but 
the  points  where  it  has 
the  requisite  degree  of 
thinness      to     produce 
segophony. 

Pleuritic  effusion. 

Pleuro-pneumonia. 

Hydrothorax. 

Empyema. 

As  in  Table  No.  6. 

As  in  Table  No.  6. 

Mostly     Pneumo-hy- 
drothorax. 

46  AUSCULTATION  AND  PERCUSSION. 

TABLE   NO.  9. 


VARIETIES. 

character  of  the  sound. 

HOW  PRODUCED. 

Normal  Vesic- 
ular 

Resonance. 

(Pulmonary.) 

A   full,    clear,   prolonged 
sound,  of  low  pitch,  its  qual- 
ity sui  generis,  only  to  be  ap- 
preciated by  actually  hearing 
it,  and  its  intensity  varying 
with  the  force  of  the  blow, 
the   elasticity  of    the  chest 
walls,  the   thickness  of  the 
layer  of  muscles  and  fat  cov- 
ering them,  and  the  degree 
of  inflation  of  the  lungs. 

By  the  vibration  of  the 
air  in  the  uniform,  elastic, 
spongy  tissue  of  the  lung 
when  percussed. 

Flatness. 

(Absence  of  reso- 
nance.) 

The    sound    is    completely 
deadened,  and  resembles  that 
produced  by  percussing  the 
thigh     or    shoulder.       The 
finger  used  as  a  pleximeter 
experiences  a  greater  sense 
of  resistance   than   normal, 
especially  in  early  life,  before 
the    costal    cartilages    have 
ceased  to  be  elastic. 

The  absence  of  resonance 
is  occasioned  by  serum  or 
pus  in  the  pleural  sac,  serum 
in  the  air-vesicles,  complete 
solidification  of  lung  tissue, 
tumors,  etc. 

Dullness. 

(Diminished  reso- 
nance.) 

Intermediate  between  the 
two  preceding,  the  vesicular 
resonance  being  not  lost  but 
only  partially  deadened.    The 
degree  of  dullness  varies  in- 
definitely.      The     pitch     is 
higher  than   normal.      The 
sense    of    resistance    is    in- 
creased in  proportion  to  the 
degree  of  dullness. 

.  By  the  same  causes  as  the 
preceding,  though  existing; 
to  a  lesser  extent.  The  rela- 
tive proportion  of  solids  or 
liquids  to  air  in  the  lungs  is 
morbidly  increased. 

AUSCULTATION  AND  PERCUSSION. 
PERCUSSION  SIGNS. 


47 


WHERE   OBSERVED   IN   HEALTH. 


Most  strongly  marked  in  the  infra- 
clavicular regions.  In  the  scapular 
and  interscapular  regions,  on  account 
of  the  layers  of  bone  and  muscles,  the 
resonance  is  diminished,  as  it  is  also 
where  the  lung  overlaps  the  heart  and 
liver.  In  different  regions  the  reso- 
nance varies  so  much  that  what  would 
be  normal  for  one  would  be  decidedly 
abnormal  for  another.  Each  must  be 
carefully  studied  by  itself.  The  area  of 
healthy  resonance  is  of  course  greater 
with  a  full  inflation  of  the  lungs  than 
in  tranquil  breathing,  and  less  with  a 
forced  expiration. 

In  some  persons  the  resonance  is  slightly 
diminished  on  the  right  side  in  the  infra- 
clavicular region  in  health,  but  never  on  the 
left  side. 


Over  the  liver  below  the  line  of  he- 
patic flatness. 

The  lower  border  of  the  right  lung  marks 
the  line  of  hepatic  flatness,  and  the  upper 
border  of  the  underlying  liver  the  line  of 
hepatic  dullness. 


Over  the  heart  and  spleen ;  in  the 
places  where  the  lungs  overlap  the 
liver  or  heart ;  over  the  mammary 
gland  in  females ;  over  thick  layers  of 
muscles  on  the  ribs,  especially  behind ; 
and  all  over  the  chest  in  very  fat  per- 
sons. 

In  some  persons  there  is  in  health  a  slight 
degree  of  dullness  at  the  summit  of  the  chest 
on  the  right  side. 


DISEASES  INDICATED. 


Pneumonia. 
Pleuritic  effusion. 
Empyema. 
Hydrothorax. 

Phthisis,  pulmonary  oedema,  condensation 
of  lung  from  compression  or  from  pulmonary 
collapse,  cancer,  aneurism,  etc. 


The  same  diseases  as  the  above, 
where  the  same  physical  conditions 
exist  to  a  less  extent.  In  many  of 
them  dullness  is  more  common  than 
flatness.  The  deposit  of  phthisis  is 
very  rarely  sufficient  to  give  rise  to 
more  than  dullness,  and  miliary  tuber- 
cles, unless  in  great  quantities,  may 
not  even  give  rise  to  dullness.  Con- 
gestion of  the  lung  may  give  rise  to 
dullness,  but  never  to  flatness. 

Rarely  we  find  dullness  in  emphysema, 
owing  probably  to  increased  tension  of  lungs 
and  walls  of  chest.  There  may  be  slight  dull- 
ness from  exudation  of  lymph  on  pleura. 


48  AUSCULTATION  AND  PERCUSSION. 

TABLE   NO.  9,  Continued. 


VARIETIES. 


Tympanitic 
Resonance. 


CHARACTER  OF   THE   SOUND. 


A  drum-like  sound,  as  its 
name  signifies ;  the  term 
often  used  to  denote  any  res- 
onance which  is  not  vesic- 
ular. It  is  of  variable  in- 
tensity, either  greater  or  less 
than  the  vesicular,  of  higher 
pitch,  and  accompanied  with 
a  sense  of  less  resistance  to 
the  finger. 


HOW  PRODUCED. 


It  requires  for  its  produc- 
tion a  large  space  filled  with 
air,  and  bounded  by  moder- 
ately tense,  elastic  walls,  capa- 
ble of  reflecting  sonorous  vi- 
brations. If,  however,  the 
tension  is  extreme,  the  con- 
tained air  does  not  vibrate, 
the  tympanitic  quality  is 
lessened  or  destroyed,  and 
the  sound  may  become  quite 
dull.  When  a  common  drum 
is  made  extremely  tight  and 
there  is  ho  escape  for  the  air, 
the  same  dull  effect  is  pro- 
duced on  being  struck. 

Tympanitic  resonance  oc- 
curs under  the  following  con- 
ditions :  — 

1 .  From  air  or  gas  in  the 
pleural  cavity.  (Here  the 
resonance  is  more  intense 
than  the  normal  vesicular.) 

2.  From  air  in  pulmonary 
cavities. 

3.  Singularly  enough,  and 
contrary  to  what  might  be 
expected,  tympanitic  reso- 
nance is  often  heard  over 
partially  solidified  lung  (giv- 
ing place  to  dullness  when 
the  solidification  becomes 
complete). 

Where  the  upper  lobe  is  thus 
resonant,  as  in  phthisis  before 
cavities  have  formed,  and  in  pneu- 
monia, it  is  generally  explained 
by  saying  that  the  resonance  must 
come  from  the  air  in  the  lower 
part  of  the  trachea  and  the  pri- 
mary bronchi,  being  better  con- 
ducted by  solidified  than  by 
healthy  lung  ;  and  where  the 
lower  lobe  is  solidified,  that  the 
tympanitic  resonance,  if  present, 
is  conducted  in  a  similar  way  from 
the  stomach  or  colon.  Fuller, 
however,  thinks  it  comes  from  the 
presence  of  air  pent  up  in  lung 
tissue  in  the  immediate  vicinity  of 
consolidated  tissue.  Skoda  and 
others  explain  it  by  diminution  of 
tension. 


AUSCULTATION  AND  PERCUSSION. 
PERCUSSION    SIGNS,   Continued. 


49 


WHERE   OBSERVED    IN   HEALTH. 


Heard  over  the  stomach  and  bowels. 


DISEASES   INDICATED. 


Pneumothorax. 

Pneumo-hydrothorax. 

Phthisis. 

Cavities  after  abscess,  etc. 
Dilatation  of  bronchi. 
Pneumonia. 


50  AUSCULTATION  AND  PERCUSSION. 

TABLE  NO.  9,  Continued. 


VARIETIES. 


Exaggerated 
Resonance. 

(Vesiculo-tym- 
panitic.) 


Amphoric 
Resonance. 


Cracked-Metal 

Resonance. 

(Bruit  du  pot  fel(5.) 


character  of  the  sound. 


Intermediate  between  the 
normal  vesicular  and  the 
tympanitic  resonance,  and 
partaking  of  the  characters 
of  each.  The  pitch  high  in 
proportion  as  the  tympanitic 
quality  predominates.  In- 
tensity greater  than  normal. 


A  kind  of  musical  intona- 
tion, like  the  sound  obtained 
by  percussing  an  empty  jar 
(amphora).  It  may  be  imi- 
tated by  closing  the  mouth, 
inflating  the  cheeks,  but  not 
too  tensely,  and  then  filliping 
them  with  the  finger. 


Like  the  sound  produced 
by  striking  a  cracked  earth- 
enware or  metal  jar  or  other 
vessel.  Can  be  imitated  by 
the  school-boy  trick  of  fold- 
ing the  hands  so  as  to  form 
a  hollow,  and  striking  the 
back  of  one  of  them  on  the 
knee.  A  loud,  short,  hollow, 
metallic  sound,  accompanied 
with  hissing. 


HOW  PRODUCED. 


1 .  By  abnormal  dilatation 
of  the  air  cells. 

2.  If  the  effusion  in  pleu- 
risy rises  much  above  the 
middle  of  the  chest,  the  pres- 
sure condenses  the  lung  above 
the  liquid,  and  dullness  en- 
sues. With  a  less  amount 
of  liquid,  however,  the  reso- 
nance is  generally  exaggera- 
ted. Also,  where  pneumonia 
solidifies  one  lobe,  the  reso- 
nance over  the  other  is  gen- 
erally exaggerated.  Prob- 
ably both  cases  are  explained 
by  assuming  a  condition  ap- 
proximating to  emphysema 
in  the  lobe  above  the  liquid 
in  pleurisy,  and  in  the 
healthy  lobe  in  pneumonia, 
they  expanding  proportion- 
ally to  the  expansion  caused 
by  the  diseased  condition  in 
the  affected  part. 


The  cavity  must  contain 
air,  must  have  somewhat 
rigid  walls,  must  be  super- 
ficial or  else  covered  by  so- 
lidified lung,  and  there  must 
be  free  communication  with 
the  bronchial  tubes.  The 
sound  can  be  heard  better 
if  the  ear  or  stethoscope  is 
brought  close  to  the  patient's 
open  mouth.  Use  slow  and 
heavy  percussion. 


Produced  exactly  as  in  the 
school-boy  trick  referred  to, 
by  the  sudden  expulsion  of 
air,  and  its  forcible  contact 
with  the  sides  of  the  passage 
through  which  it  is  driven. 
The  same  conditions  are  nec- 
essary to  its  production  as  in 
amphoric  resonance. 


AUSCULTATION  AND  PERCUSSION. 
PERCUSSION   SIGNS,  Continued. 


51 


WHERE  OBSERVED   IN  HEALTH. 

DISEASES   INDICATED. 

Emphysema  (vesicular  or  interlob- 
ular or  secondary  to  phthisical  de- 
posit, etc.). 

Pleurisy  with  effusion. 

Pneumonia. 

Occasionally  produced  in  children 
over  a  primary  bronchus,  owing  to  the 
yielding  of  the  costal  cartilages. 

Mostly    phthisical    cavities,    some- 
times pneumo-hydrothorax. 

Occasionally  at  the  summit  of  the  chest  in 
pleurisy  with  effusion. 

As  in  the  preceding. 

It  may  be  produced  unintentionally 
by  the  imperfect  application  of  the 
finger  or  pleximeter  to  the  chest  walls, 
and  the  expulsion  of  air  from  beneath 
it. 

Mostly  phthisical  cavities. 

Occasionally  in  solidification  of  the  upper 
lobe    from    inflammation    or    condensation, 
where  the  air  is  suddenly  and  forcibly  ex- 
pelled through  the  bronchus,  especially  if 
percussed  near  the  sternum. 

PART  II. 

THE  PHYSICAL  DIAGNOSIS  OF  DISEASES 
OP  THE  LUNGS  AND  HEART. 


54 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.   10. 


DISEASE. 

INSPECTION    AND 
MENSURATION. 

PERCUSSION. 

RESPIRATION. 

Acute 
Pleukist. 

First  Stage. 

(Exudation  of 
lymph.) 

Diminution      in 
respiratory    move- 
ments on   account 
of  pain.  Body  bent 
towards      affected 
side  for  the  same 
reason. 

Sometimes  slight 
dullness. 

Feeble. 
Jerking. 

Second  Stage. 

(Effusion  of 
serum.) 

Little  or  no  mo- 
tion of  the   chest 
walls  on  the  affect- 
ed   side,     but    in- 
creased motion  on 
the  healthy  side. 

Enlargement  of 
side    in  all   direc- 
tions by  measure- 
ment, and  oblitera- 
tion of  intercostal 
spaces,     especially 
at    lower  part    of 
chest. 

A  sense   of    re- 
sistance,  and  flat- 
ness or  dullness  at 
the    base    of    the 
chest,  terminating 
abruptly  above   in 
a  curved  line  which 
is   not    altered    by 
respiration,        but 
which  may  be  made 
to  shift  by  chang- 
ing   the    patient's 
posture,     unless 
there  are  adhesions 
of  the  pleural  sur- 
faces, or  the  chest 
is  full  of  liquid. 

Generally  exag- 
gerated resonance 
above  the  level  of 
the      liquid,     and 
rarely  the  amphoric 
or     the     cracked- 
metal  resonance  at 
the  summit. 

Feeble,  broncho- 
vesicular  or  bron- 
chial respiration 
over  the  compressed 
lung,  with  occa- 
sionally a  feeble, 
distant,  bronchial 
respiration  all  over 
the  chest. 

Respiration  gen- 
erally suppressed 
below  the  level  of 
the  liquid,  but  in- 
creased on  unaf- 
fected side  during 
all  three  stages, 
especially  in  this 
stage. 

Third  Stage. 

(Absorption  and 
resolution.) 

Mobility  of  chest 
walls  partially  re- 
turning, intercostal 
spaces      becoming 
normal,    and     en- 
largement    disap- 
pearing. 

After     recovery 
there     occurs,     in 
some      cases 
(though  seldom  in 
comparison      with 
chronic    pleurisy), 
contraction  of  the 
whole  side. 

The  line  of  flat- 
ness   is   gradually 
lowered,  but  dull- 
ness often  remains 
for    an    indefinite 
time  at  the  base  of 
the    chest,    where 
the  compression  of 
the  lung  and   the 
accumulation       of 
solid  plastic  mate- 
rial is  often  very 
great. 

Respiration  grad- 
ually returns  to  its 
normal  condition 
from  the  summit 
downwards,  though 
feeble  often  for 
weeks  and  months. 

Absence  of  respi- 
ration at  the  base 
frequently  remains 
for  a  long  time. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE   NO.    10. 


55 


RALES. 

VOCAL 
RESONANCE. 

TALFATION. 

REMARKS. 

Rubbing  friction 
sounds  often 
heard,  which  are 
almost  pathogno- 
monic   when    at 
the  middle  or  infe- 
rior part  of  chest, 
or  all  over  the  side. 

Deep-seated      ten- 
derness. 

When  not  spe- 
cified,   the   signs 
mentioned  in  this 
table      are     ob- 
served over  the 
affected     portion 
of  the  lung  only. 

A    friction 
sound    is    rarely 
heard  even  in  this 
stage,  where  the 
lung  is  attached 
by  bands  of  false 
membrane  to  the 
thoracic      walls, 
and  also  over  the 
compressed  lung 
higher  up. 

Lessened      or 
suppressed  below 
the  level  of  the 
liquid,    but     in- 
creased above. 
Sometimes  bron- 
chophony above 
the  level,  or  pec- 
toriloquy   (espe- 
cially  in  pleuro- 
pneumonia,     or 
pleurisy    with 
phthisis),    heard 
best     over     the 
scapular  and  in- 
terscapular    re- 
gions on  account 
of  the  usual  sit- 
uation    of     the 
compressed  lung. 
Sometimes 
segophony    near 
the   level  of  the 
liquid. 

Fluctuation  some- 
times apparent.    Vo- 
cal fremitus  lessened 
or  suppressed  below 
the  level  of  the  liquid, 
but  increased  above. 

If  the  heart  is  dis- 
placed,   it    may    be 
heard  and  often  felt 
pulsating  even  to  the 
right  of  the  sternum, 
or  farther  to  the  left 
than  normal   in  the 
direction  of   the  ax- 
illa ;    the     displace- 
ment   being    to  the 
right  if  the  effusion 
is  on  the  left  side,  and 
to  the  left  if  the  effu- 
sion is  on  the  right 
side. 

Generally    the 
pleural  cavity  is 
not    more     than 
half  or  two  thirds 
full      in      acute 
pleurisy. 

« 

A  rasping,  grat- 
ing, creaking, 
rough,  fr  ictio  n 
murmur     is    now 
very    often     ob- 
served, especially 
with   a   deep   in- 
spiration,    some- 
times loud  enough 
to  be  heard  at  a 
distance,  and  va- 
rying in  duration 
from  a  very  short 
time    to    several 
months,     ceasing 
with  adhesion. 

Gradually  ap- 
proaches to  the 
normal.     Some- 
times segophony. 

Sometimes  a  fric- 
tion   fremitus.     The 
heart,    if  previously 
displaced,   gradually 
returns  to  the    prse- 
cordia,    unless    held 
by  morbid  adhesions ; 
and  curiously  enough, 
the      suction     force 
caused  by  absorption 
may  now  even  draw 
it  too  far  in  the  oth- 
er direction,  —  if  the 
effusion     has      been 
right-sided,    towards 
the    right ;     if    left- 
sided,  further  to  the 
left  than  normal. 

56 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


Chronic 
Pleurisy. 

(If  the  chest  is 
full  of  fluid.) 


Empyema. 


INSPECTION  AND 

MENSURATION. 


Perfect  or  almost 
perfect  immobility 
of  side  of  chest 
(with  increase  of 
motion  on  healthy 
side).  Generally  di- 
latation of  side, 
and  as  a  rule,  even 
if  this  be  not  so, 
the  intercostal  de- 
pressions are  ef- 
faced or  lessened. 
This  is  particularly 
noticeable  at  the 
end  of  inspiration. 
The  maximum  en- 
largement of  the 
side  is  about  two 
inches. 

Permanent  con- 
traction after  re- 
covery. 


The  amount  of 
pus  is  generally 
even  greater  than 
that  of  the  serum 
in  chronic  pleurisy, 
causing  still  greater 
dilatation  of  the 
chest.  The  obliter- 
ation of  intercostal 
depressions  is  oft- 
ener  noticed  than 
in  pleurisy. 


PERCUSSION. 


Flatness  every- 
where on  affected 
side,  even  extend- 
ing over  the  ster- 
num some  distance 
on  the  other  side. 


Same  as  chronic 
pleurisy. 


RESPIRATION. 


Wanting ;  except 
at  the  summit  over 
or  near  the  com- 
pressed lung,  where 
it  is  bronchial.  Ex- 
ceptionally, how- 
ever, the  bronchial 
respiration  extends 
over  the  whole  side 
or  the  greater  part 
of  it. 

Eespiratory  mur- 
mur exaggerated  on 
healthy  side. 


Same  as  chronic 
pleurisy. 


OF  DISEASES   OF   THE  LUNGS. 
TABLE  NO.  10,   Continued. 


57 


rXles. 

VOCAL 
RESONANCE. 

PALPATION. 

REMARKS. 

As     in     acute 
pleurisy. 

Lessened      o  r 
suppressed     ex- 
cept at  the  sum- 
mit   behind, 
where  there  may 
be  loud  and  whis- 
pering bron- 
chophony and  in- 
creased vocal  res- 
onance. iEgoph- 
ony  is  rare. 

Fluctuation   some- 
times apparent.   Vo- 
cal fremitus  lessened 
or  suppressed. 

Heart       displaced 
even    more    than   is 
usual  in  acute  pleu- 
risy.      Mediastinum 
displaced      laterally. 
Liver    and    stomach 
often  displaced  down- 
wards, sometimes  as- 
cending even  higher 
than  before  with  the 
contraction      accom- 
panying recovery. 

If  the  chest  is 
only  partially 
filled,   the    signs 
are   the  same  as 
in  acute  pleurisy. 
It    is    far    more 
common  to  have 
the   chest  full  in 
chronic    than   in 
acute  pleurisy. 

Same  as  chron- 
ic pleurisy. 

Same  as  chron- 
ic pleurisy. 

Even     more     dis- 
placement    of      the 
heart  generally  than 
in  chronic   pleurisy, 
it     pulsating     some- 
times   even     beyond 
the  right  nipple.     If 
the  left  side  is  affect- 
ed, the  effusion  often 
receives    a    tangible 
and  visible  impulse 
from  the  heart's  beat ; 
hence  the  term  "  pul- 
sating empyema." 

If    a    spontaneous 
perforation     takes 
place     through     the 
chest  walls,  and  the 
skin      remains     un- 
broken,   the     tumor 
thus  formed,  besides 
fluctuating,  often  has 
a    strong    pulsation, 
synchronous  with  the 
systole,     simulating 
aneurism.      The  tu- 
mor   may    also     in- 
crease and  decrease 
with  respiration. 

58 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.   10,  Continued. 


DISEASE. 

INSPECTION   AND 
MENSURATION. 

PERCUSSION. 

RESPIRATION. 

Hydro- 
thorax. 

Although    there 
may  be  more  liquid 
on  one  side  than  on 
the  other,  yet  there 
is  almost  never  one- 
sided dilatation  of 
the  chest  and  dis- 
placement  of    the 
heart  and  medias- 
tinum. 

Flatness  or  dull- 
ness over  the  lower 
part  of  both  sides 
of  the  chest.     The 
line  of  flatness  al- 
most     always 
changes    with 
change  of  posture. 
Of  course  it  is  im- 
possible   for  both 
pleural  cavities  to 
be  completely 
filled. 

As     in     pleurisy 
with   moderate    ef- 
fusion.      There   is 
rarely,  however, 
well-marked    bron- 
chial    respiration, 
as,  the  disease  being 
bilateral,    sufficient 
compression  to  pro- 
duce bronchial  res- 
piration  could   not 
often  be  compatible 
with  life. 

Pulmonary 
(Edema. 

More  or  less  dull- 
ness, generally  dif- 
fused equally  over 
the    back    of    the 
chest  on  both  sides, 
and    most  marked 
at  the  lowest  parts. 

Weakened  or 

suppressed. 

K  a  r  e  1  y      well- 
marked     bronchial 
respiration. 

OF  DISEASES   OF   THE  LUNGS. 
TABLE   NO.  10,   Continued. 


VOCAL 

KALES. 

RESONANCE. 

PALPATION. 

REMAHKS. 

No     exudation 

As  in  pleurisy 

Vocal     fremitus 

Hydrothorax  is 

of     lymph     and 

with     moderate 

lessened       or     sup- 

bilateral ;    while 

therefore  no  fric- 

effusion. 

pressed     below     the 

the  different 

tion  sounds. 

level  of   the    liquid, 

kinds  of  pleurisy 

but  increased  above. 

are  almost  with- 
out exception 
unilateral. 

Subcrepitant 
and  fine  bubbling 

Variable. 

Vocal  fremitus  va- 

Like  hydro- 

riable. 

thorax,      pulmo- 

rales. 

nary  oedema  is  a 
result  of  structu- 
ral disease  of  the 
heart  or  kidney. 
Although  gen- 
erally bilateral, 
and  then  oftener 
found  in  the  pos- 
terior portions,  it 
may  be  unilateral 
and  extend  over 
one  lobe  or  a 
whole  lung. 

60 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,   Continued. 


Pneumo- 
hydrotho- 

KAX. 


INSPECTION    AND 
MENSURATION. 


Expansion  of 
affected  side  and 
relative  mobility 
impaired.  Ob- 
literation and 
sometimes  bulg- 
ing of  intercostal 
depressions. 


PERCUSSION. 


Flatness  at  the  base 
of  the  chest  on  the 
affected  side,  if  there 
be  enough  liquid  (se- 
rum or  pus).  Over 
the  upper  part  of  the 
same  side  and  some- 
times extending  be- 
yond the  sternum, 
tympanitic  resonance 
almost  as  intense  as 
that  of  a  tympanitic 
abdomen.  This  is 
heard  by  conduction 
even  below  the  level 
of  the  liquid,  the  lat- 
ter often  extending 
twice  as  high  as  the 
line  of  flatness. 

The  tympanitic  res- 
onance extends  over 
the  whole  side,  if 
there  be  only  a  small 
amount  of  liquid. 
Change  of  posture 
always,  in  this  dis- 
ease, changes  relative 
position  of  flatness 
and  tympanitic  reso- 
nance. Sometimes 
there  is  amphoric  res- 
o  nance.  Dullness 
from  the  condensed 
lung  may  sometimes 
be  detected  at  the 
summit  of  the  chest 
behind.  If  the  quan- 
tity of  air  or  gas  be 
very  lai'ge,  on  account 
of  the  extreme  tension 
there  may  be  tympa- 
nitic dullness. 


RESPIRATION. 


Suppressed  be- 
low the  level  of  the 
liquid.  Eeeble,  dis- 
tant or  suppressed 
above,  unless  there 
is  a  free  communi- 
cation between  the 
bronchial  tubes  and 
the  pleural  cavity 
above  the  level  of 
the  liquid,  when 
there  may  be  heard 
amphoric  respira- 
tion, limited  to  a 
circumscribed  area 
near  the  perfora- 
tion, which  is  gen- 
erally between  the 
third  and  sixth  ribs 
on  the  postero-lat- 
eral  surface  of  the 
chest. 

Bronchial  respi- 
ration over  the  con- 
densed lung  (which 
is  generally  also 
tuberculous),  at  the 
top  of  the  chest 
behind. 

Respiration  on 
healthy  side  exag- 
gerated. 


OF  DISEASES   OF   THE  LUNGS. 
TABLE  NO.  10,  Continued. 


61 


Metallic  tink- 
ling, and  splash- 
ing or  Hippo- 
cratic  succussion 

sound. 


VOCAL 

RESONANCE. 


Above  the  liquid 
amphoric  whisper, 
voice,  and  cough,  if 
there  is  amphoric 
respiration.  Or  the 
vocal  resonance  may- 
be feeble  or  wanting. 
Always  wanting  be- 
low the  liquid.  Me- 
tallic tinkling. 

Increased  vocal  res- 
onance or  bronchoph- 
ony over  the  com- 
pressed lung  at  'the 
top  of  the  chest  be- 
hind. 


PALPATION. 


Vocal  fremitus 
diminished  or 
suppressed. 

Displacement 
of  heart.  Fluc- 
tuation. Sense 
of  elasticity 
above  and  of  re- 
sistance below 
the  level  of  the 
liquid. 


When  this  dis- 
ease occurs,  it  is 
generally  a  com- 
plication of 
phthisis. 

The  relative 
proportion  of  air 
or  gas  and  water 
varies  in  different 
cases  and  in  the 
same  case  at  dif- 
ferent times,  es- 
pecially if  com- 
munication with 
the  external  air 
continues. 


62 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


Pneumo- 
thorax. 


Emphy- 
sema. 


INSPECTION    AND 
MENSURATION. 


As  in  the  preceding. 


There  is  a  character- 
istic deformity  of  the 
chest,  a  great  bulging 
of  the  whole  upper  part 
generally,  sternum  and 
all. 

The  antero-posterior 
diameter  of  the  chest 
is  greatly  increased. 
The  clavicles  are  ele- 
vated, and  yet  almost 
buried  up.  The  lower 
parts  of  the  scapulas 
sometimes  project.  The 
entire  thorax  is  dragged 
upwards  as  one  piece  in 
inspiration,  but  there  is 
little  or  no  expansion 
of  the  chest,  because  the 
elasticity  of  the  lung 
tissue  being  lost,  expi- 
ration fails  to  empty  the 
chest,  and  there  is  little 
room  for  the  introduc- 
tion of  fresh  air. 

Respiratory  efforts 
labored  and  powerful, 
yet  the  breathing  is 
chiefly  abdominal,  and 
the  lower  part  of  the 
chest  may  even  sink  in 
during  inspiration.  De- 
pression above  clavicles 
in  inspiration. 

The  patient  often 
stoops  from  antero-pos- 
terior curvature  of  the 
spine. 

In  a  few  cases  of  the 
variety  called  "senile 
atrophy  "  of  the  lung 
there  is  no  bulging. 


PERCUSSION. 


Tympa  n  i  t  i  c 
resonance  over  a 
part  or  the  whole 
of  the  affected 
side,  sometimes 
even  extending 
to  the  right  or 
left  beyond  the 
sternum. 


Exaggera  ted 
resonance  (some- 
times called  ves- 
iculo-tympa- 
nitic),  on  both 
sides,  but  gen- 
erally greater 
on  the  left.  It  is 
heard  over  a 
greater  area  than 
the  vesicular  res- 
onance in  health, 
as  the  diaphragm 
is  pushed  down 
and  the  heart  is 
more  or  less  com- 
pletely covered 
by  lung.  Owing 
to  the  slight 
movement  of  the 
lungs,  this  area 
is  not  much  af- 
fected by  forced 
inspiration  or  ex- 
piration. 

If  the  lower 
lobes  are  em- 
physematous, the 
line  of  hepatic 
flatness  may  be 
lowered  to  the 
ninth  or  tenth 
rib  on  the  per- 
pendicular mam- 
mary line. 

In  exceptional 
cases,  there  may  be 
some  dullness  on 
percussion. 


RESPIRATION. 


Respiration  sup- 
pressed where  the 
air  is,  or  it  may  be 
amphoric  if  there  is 
free  communication 
between  the  bron- 
chial tubes  and  the 
pleural  cavity.  Bron- 
c  h  i  a  1  respiration 
over  the  condensed 
lung.  Exaggerated 
on  the  healthy  side. 


Weakened  or 
suppressed  over  the 
upper  lobes,  more 
so  usually  on  the 
left  than  on  the 
right  side.  Inspi- 
ratory sound  short- 
ened and  expiration 
remarkably  pro- 
longed, though  of 
the  same  quality 
as  in  health. 


OF  DISEASES   OF   THE  LUNGS. 
TAELE  NO.  10,  Continued. 


63 


If  bronchitis 
aDd  asthma  co- 
exist, bubbling 
rales,  and  oft- 
ener  sibilant 
and  sonorous 
rales. 


VOCAL 
RESONANCE. 


Diminished  or  sup- 
pressed where  the  air 
is,  or  amphoric  voice, 
whisper,  and  cough, 
if  there  is  amphoric 
respiration.  Vocal 
resonance  increased 
over  the  condensed 
lung,  or  even  bron- 
chophony. 


Vocal      resonance 
variable. 


PALPATION. 


Vocal  fremitus 
diminished  or 
suppressed  where 
the  air  is,  hut 
increased  over 
the  condensed 
lung.  Displace- 
ment of  heart. 


Vocal  fremitus 
variable. 

Heart's  im- 
pulse lowered, 
sometimes  being 
felt  in  the  epi- 
gastrium instead 
of  in  the  pre- 
cordial space. 

Chest  walls  un- 
usually elastic 
to  the  finger. 


A  very  rare  dis- 
ease, air  or  gas 
without  liquid  almost 
never  being  found 
in  the  chest. 

Pneumo-hydrotho- 
rax  is  often  loosely 
called  pneumotho- 
rax, however. 


In  the  great  ma- 
jority of  cases, 
vesicular  emphy- 
sema has  associ- 
ated with  it  chronic 
bronchitis.  It  is 
often  accompanied 
by  paroxysms  of 
asthma. 

Generally  a  bilat- 
eral disease,  al- 
though there  is 
usually  more  affec- 
tion of  the  left 
lung  than  of  the 
right. 


64 


THE  PHYSICAL  DIAGNOSIS 


TABLE  NO.  10,   Continued. 


Asthma. 


Bronchitis. 

(Affecting  the 
larger  tubes.) 


INSPECTION  AND 
MENSURATION. 


Often  a  bulg- 
ing of  the  upper 
part  of  the  chest, 
and  a  sinking  in, 
during  inspira- 
tion, of  the  lower 
part,  on  account 
of  the  emphy- 
sema which  gen- 
erally coexists. 
,  Labored  res- 
piration. 


PERCUSSION. 


Owing  to  the 
commonly  coexist- 
ing emphysema, 
there  is  generally 
exaggerated  per- 
cussion resonance, 
as  in  that  disease. 


Healthy  reso- 
nance on  both 
sides  of  the  chest. 
A  negative  sign, 
but  a  good  one 
here. 

Rarely  a  slight  dull- 
ness at  the  lower  part 
of  the  back  of  the 
chest,  from  excessive 
secretion  which  can- 
not be  raised,  or  from 
collapse  of  pulmonary 
lobules  from  obstruc- 
tion of  bronchial 
tubes. 


RESPIRATION. 


Diminished  or  sup- 
pressed. 

Sometimes  exag- 
gerated. 

Jerking. 


In  many  cases  nor- 
mal. 

Sometimes  ob- 
scured by  the  rales, 
sometimes  weakened 
or  suppressed  over  a 
part  of  the  chest  by 
plugs  of  mucus  in 
tubes,  suddenly  reap- 
pearing after  cough- 
ing, sometimes  by 
thickening  of  the 
mucous  membrane ; 
but  from  this  latter 
cause  both  sides  are 
affected  alike. 


OF  DISEASES  OF  THE  LUNGS. 


65 


TABLE   NO.  10,    Continued. 


Loud  sibilant  and 
sonorous  rales  with  in- 
spiration and  expira- 
tion (the  sibilant, 
however,  being  more 
abundant  in  inspira- 
tion, and  the  sonorous 
in  expiration),  all  over 
the  chest  on  both 
sides  and  often  heard 
at  a  distance. 

Sometimes  bubbling 
rales  towards  the  close 
of  the  paroxysms  and 
for  several  days  after, 
when  they  cease,  un- 
less chronic  bronchitis 
coexists. 


On  both  sides  of  the 
chest,  especially  over 
the  lower  lobes  be- 
hind, sonorous  and  sib- 
ilant rales,  according 
to  the  size  of  the  tubes 
in  which  they  are  pro- 
duced, are  sometimes 
heard  alone,  before 
secretion  takes  place, 
and  after  this  mingled 
with  coarse  and  fine 
bubbling  rales.  In 
many  cases  no  rales 
are  heard  at  all,  and 
when  present  they  of- 
•ten  shift  their  posi- 
tion. The  moist  rales 
are  not  heard  unless 
the  mucus  is  unusual- 
ly thin  and  abundant, 
which  is  not  the  case 
in  many  instances. 
They  occur  oftener 
in  chronic  than  in 
acute  bronchitis,  he- 
cause  in  the  former 
the  liquid  is  more  apt 
to  be  muco-purulent, 
and  therefore  pro- 
duces better  bubbles. 
They  occur  oftener 
also  in  young  chil- 
dren than  in  adults, 
because  the  former 
expectorate  less. 


VOCAL 
RESONANCE. 


PALPATION. 


Sometimes  a 
rhonchial  fremi- 
tus. 


REMARKS. 


T  h  e  physical 
signs  given  are 
those  of  a  parox- 
ysm. This  is 
generally  accom- 
panied by  a  tem- 
porary emphyse- 
matous condition 
at  least,  and  by 
bronchitis. 

Regular  asth- 
matics often  have 
these  for  perma- 
nent complica- 
tions. 


A  bilateral  dis- 
ease. 


66 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


DISEASE. 

inspection  and 
mensuration. 

PERCUSSION. 

RESPIRATION. 

Capillary 
Bronchitis. 

(Including  catar- 
rhal pneumonia.) 

If  there  is  con- 
siderable   collapse 
of  pulmonary  lob- 
ules, with  emphy- 
sema, and  with  or 
without    catarrhal 
pneumonia,  the  up- 
per   part    of     the 
chest    is    more  or 
less  expanded,  and 
the  lower  part  may 
even  sink  in  during 
inspiration. 

Undiminished  res- 
onance    on     both 
sides  of  the  chest, 
except    sometimes 
when  there  is  col- 
lapse of  pulmonary 
lobules     with     or 
without     catarrhal 
pneumonia,    when 
there  may  be  some 
circumscribed  dull- 
ness over  dissemi- 
nated  portions    of 
the  lung,  especially 
over      the      lower 
lobes   behind,   and 
exaggerated    reso- 
nance     in      other 
parts,       especially 
the  upper  part  of 
the  chest  in  front, 
if  emphysema   co- 
exists. 

Respiration  weak- 
ened or  obscured  by 
rales.  If  solidifica- 
tion from  collapse 
coexists  (with  or 
without  catarrhal 
pneumonia),  bron- 
cho-vesicular or 
bronchial  or  weak- 
en e  d  respiration 
over  such  parts.  If 
emphysema  coex- 
ists, weak  or  sup- 
pressed inspiration 
in  front  above,  and 
expiration  length- 
ened. 

Plastic 
Bronchitis. 

(Pseudo-mem- 
branous.) 

No  dullness  un- 
less from  collapse, 
or      from       great 
quantity   of  liquid 
in  bronchi. 

There  may  be 
suppression  of  res- 
piration over  parts 
of  the  chest  from 
the  exudation  or 
from  collapse ;  or 
broncho  -  vesicular 
or  bronchial  respi- 
ration from  col- 
lapse. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,  Continued. 


67 


RALES. 

VOCAL 
RESONANCE. 

PALPATION. 

REMARKS. 

Subcrepitant  rales 
uniformly  present  on 
both  sides  of  the  chest, 
with    either    or   both 
respiratory    acts,    es- 
pecially     over      the 
lower    third    of    the 
chest  behind. 

Sibilant  and   sono- 
rous,   especially  sibi- 
lant   rales,    and    also 
fine  and  coarse  bubbling 
rales  may  be  heard  all 
over  the  chest  on  both 
sides  when  the  smaller 
and  larger  tubes  are 
also  affected. 

If      solidifica- 
tion    from    col- 
lapse exists,  with 
or  without  catar- 
rhal pneumonia, 
increased    vocal 
resonance  or 
broncho  phony 
over  such  parts. 

If      solidifica- 
tion   from    col- 
lapse exists,  with 
or  without  catar- 
rhal pneumonia, 
increased    vocal 
fremitus        over 
such  parts. 

A  bilateral  dis- 
ease. Inflamma- 
tion of  the  larger 
tubes  generally 
coexists.  Capil- 
lary bronchitis  is 
sometimes  attend- 
ed with  collapse 
o  f  pulmonary 
lobules  and  ca- 
tarrhal pneumo- 
nia, especially  in 
infants  or  in  aged 
or  feeble  persons. 
Collapse,  by  the 
law  of  compen- 
sation, generally 
gives  rise  to 
emphysema  in 
other  portions  of 
the  lung. 

Sonorous  and    sibi- 
lant   rales     on     both 
sides. 

Subcrepitant      rales 
limited  to  certain  por- 
tions of  chest.    Also 
bubbling  rales. 

There  may  be  tem- 
porary suppression  of 
rales  over  parts  of  the 
chest  from  the  exuda- 
tion, or  more  lasting 
suppression  from  col- 
lapse. 

As  in  the  pre- 
ceding. 

As  in  the  pre- 
ceding. 

A  rare  disease. 

The  fibrinous 
exudation  com- 
mences in  the 
minute  branches 
and  extends  up- 
wards. A  few  or 
many  tubes  may 
be  affected.  Col- 
lapse of  pulmo- 
nary lobules  may 
occur  from  ob- 
struction. 

Bilateral  dis- 
ease. Either 
acute  or  chronic. 

68 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


DISEASE. 

inspection  and 

mensuration. 

PERCUSSION. 

RESPIRATION. 

Acute  Lobar 

or  Croupous 

Pneumonia. 

First  Stage. 

(Congestion.) 

Sometimes  cos- 
tal movements 
on  affected  side 
diminished  on 
account  of  pain. 

There  may  be  a  slight 
dullness. 

We  akene  d 
somewhat  over 
the  cong  e  s  t  e  d 
lobe. 

Second  Stage. 
(Hepatization.) 

Costal    move- 
ments   d  i  m  i  n- 
ished  on  affected 
side     (especially 
if  the  whole  lung 
be  inflamed),  and 
increased  on  the 
other  side. 

There  may  be 
in  some  cases  a 
slight  increase  by 
measurement. 

Over  the  affected  lobe 
or  lobes  increased  sense 
of  resistance   and 
marked  dullness,  some- 
times even  amounting 
to  flatness.     The  inter- 
lobar fissure  can  be  dis- 
tinctly mapped  out  by 
percussion,   if    one    or 
two  lobes  of  the  affected 
lung  remain  unaffected, 
the  latter  giving  forth 
an    exaggerated    reso- 
nance.    In  such  cases 
the  resonance  over  the 
healthy   lung  is  i  n- 
creased,but  not  so  much 
as  over  these  unaffected 
lobes. 

In  some  cases,  instead  of 
the  usual  dullness  there  may 
be   tympanitic    or  cracked- 
metal  or  amphor i c  reso- 
nance over  part  of  an  upper 
solidified  lobe,  this  quality 
coming  from  the  air  in  the 
trachea    or    bronchi,   con- 
ducted by  the  solidification ; 
also  sometimes  at  the  base 
of  the  chest,  if  affected,  be- 
ing conducted  upwards  from 
the  stomach  or  colon. 

Broncho-vesicu- 
lar followed  by 
bronchial  respira- 
tion, as  solidifi- 
cation increases. 

Exagg  e  r  a  t  e  d 
on  healthy  side. 

OF  DISEASES   OF  THE  LUNGS. 
TABLE   NO.  10,  Continued. 


69 


BALES. 

VOCAL  RESONANCE. 

PALPATION. 

REMARKS. 

Generally,    but 
not  invariably,  the 
crepitant     rale. 
When  it  does  occur, 
it  is  pathognomonic. 

Rarely  dry  and  moist 
bronchial    rales    from 
accompanying   circum- 
scribed bronchitis,  or  a 
friction  sound  from 
secondary  pleurisy. 

Generally  a  uni- 
later  a  1  disease. 
More  common  in  a 
lower  lobe,  espe- 
cially on  the  right 
side.  When  so  situ- 
ated, the  physical 
signs  are  best  heard 
in  the  infra-scapu- 
lar and  infra-axil- 
lary regions. 

Crepitant  rale  dis- 
appears, but    occa- 
sionally  it    persists 
even  in  this  stage,  a 
few  air-cells  here 
and  there  not  being- 
filled  with    exuda- 
tion. 

Rarely   moist    bron- 
chial rales. 

Increased  vocal 
resonance  and  in- 
creased bronchial 
whisper,  followed 
by  bronchophony  and 
whispering  br  on- 
chophony,  as  solidi- 
fication increases. 

Occasionally  pec- 
toriloquy  and 
whispering  pecto- 
riloquy. 

Vocal  fremi- 
tus   generally 
increased  over 
affected     por- 
tion, but  some- 
times    dimin- 
ished, and  oc- 
casionally  ab- 
sent, owing  to 
plugging   of 
bronchi  or 
pleuritic   effu- 
sion. 

Sometimes  the 
heart's  sounds  are 
transmitted  with 
peculiar  dist  i  n  c  t- 
ness  through  the 
solidification,  some- 
times not. 

70 


THE  PHYSICAL  DIAGNOSIS 
TABLE    NO.    10,  Continued. 


DISEASE. 

inspection  and 
mensuration. 

PERCUSSION. 

RESPIRATION. 

Croupous 
Pneumonia. 

Third  Stage. 

(1.)  Resolution. 

or 

Gradual  re- 
turn to  the  nor- 
mal cond  i  t  i  o  n, 
and  after  recov- 
ery even  contrac- 
tion   may   occur 
in  some  cases. 

Dullness  grad- 
ually disappears. 
A  little,  however, 
often  remains  for 
a  long  time. 

The  bronchial 
merges  into  the  bron- 
cho-vesicular respira- 
tion, which  is  followed 
for  some  time  after 
recovery  by  weakened 
respiration. 

(2.)   Purulent 
infiltration. 

• 

Dullness   con- 
tinues, and    be- 
comes    more 
marked. 

Bronchial  respira- 
tion, or  feeble  or  sup- 
pressed respiration. 

Catarrhal 
Pneumonia. 

(Lobular  or  broncho- 
pneumonia.) 

Already 

explained  in 

connection  with 

Interstitial 

or 
Chronic  Pneu- 
monia, 
or 
Fibroid  Phthi- 
sis. 

Difference    in 
the  relative  cos- 
tal moveme  n  t  s 
on  the  two  sides, 
and  after  a  while 
contract  ion    of 
the  affected  lobe. 

Marked    dull- 
ness. 

Occas  i  o  n  a  1 1  y    a 
tympanit i c    reso- 
nance. 

Bronchial  or  bron- 
cho-vesicular. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE   NO.  10,  Continued. 


71 


RALES. 

VOCAL 
RESONANCE. 

PALPATION. 

REMARKS. 

Subcr  e  p  i  t  a  n  t 
rale  appears,  with 
sometimes  a  few 
fine    and    coarse 
bubbling   rales. 
Crepitant  rale  re- 
turns. 

Bronchophony 
and    whispering 
bronchop  h o  n  y, 
followed    by   in- 
creased    vocal 
resonanc  e    and 
increased     bron- 
chial   wh  i  s  pe  r, 
and  this  by  nor- 
mal vocal  reson- 
ance and  whisper. 

Increased  vo- 
cal fremitus,  fol- 
lowed by  the  nor- 
mal. 

Fine  and  coarse 
bubbling    rales 
generally    in 
abundance. 

Weak     bron- 
chophony or  di- 
minished    vocal 
resonance. 

Vocal  fremitus 
variable. 

If,  as  very  rarely 
happens,  an  abscess 
forms  and  discharges, 
it  may  give  rise  to  the 
same  physical  signs 
as  a  phthisical  cavity 
(which  see). 

Capillary 

Bronchitis. 

Limited  to  lobules 
scattered  through 
lung  substance  i  n 
patches  varying  i  n 
size  from  a  hemp  seed 
to  an  egg,  or  larger. 

Fine  and  coarse 
bubbling   rales, 
also  sibilant  and 
sonorous  rales. 

Increased   vo- 
cal reso  nance 
and    increased 
bronchial    whis- 
per. 

Bronchophony 
and    whispering 
bronchophony. 

Increased    vo- 
cal fremitus. 

Called  also  Cirrho- 
sis  of    Lung.     It 

leads  to  contraction 
of  the  lung  and  dila- 
tation of  the  bronchi, 
and  is  always  accom- 
panied by  bronchitis. 
A  unilateral  disease. 
Occurs  among  stone 
masons,  grinders,  etc. 
This  disease  is  "  the 
anatomical  basis  of 
almost  all  pulmonary 
phthisis." 

72 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.   10,  Continued. 


DISEASE. 

inspection  and 
mensuration. 

PERCUSSION. 

RESPIRATION. 

Acute 
Miliary 
Tuberculo- 
sis. 

When  one  lung 
is  affected  a  little 
more      than      the 
other,    there    may 
be  a  slight  excess 
of  dullness  in  the 
former.      But  oft- 
ener    there   is    no 
notable  dullness  on 
either     side,     the 
granulations,  even 
when  very  numer- 
ous, remaining  iso- 
lated. 

Phthisis. 

First  Stage. 
(Incipient.) 

Some  dullness,  es- 
pecially if  the  de- 
posit    be    at    all 
superficial,  at   the 
summit  of  the  chest 
on  one  side  (more 
often  the  left),  in 
front  or  behind. 

There    may    be 
vesiculo-tympanitic 
resonance     at    the 
apex  from   second- 
ary lobular  emphy- 
sema. 

Remember     the 
possible  very    slight 
dullness    in     health 
on    the    right    side. 
It  is  in  connection 
with  the    diagnosis 
of    incipient 
phthisis   that    this 
fact  becomes  of  the 
most    importance. 

Any     dullness, 
however  slight,  at 
the  left  apex  is  al- 
ways abnormal. 

Respiration 
weakened  or  bron- 
cho-vesicular, occa- 
sionally jerking. 

[There  may  be 
abnormal  trans- 
mission of  the 
heart  sounds 
(available  in  the 
infra-clavicular  re- 
gion), denoting  a 
deposit  on  the  right 
side,  if  the  first 
sound  be  heard 
better  here  than  on 
the  left;  and  on 
the  left  side,  if  the 
second  sound  be 
heard  better  here 
than  on  the  right.] 

OF  DISEASES  OF  THE  LUNGS. 
TABLE   NO.    10,    Continued. 


73 


Subcrepitant,  fine  and 
coarse  bubbling,  and 
sibilant  and  sonorous 
rales  in  different  places 
all  over  both  sides. 


There  may  be  one  or 
more  of  the  following 
kinds  of  rales  :  — 

1.  Subcrepitant,  indi- 
cating a  circumscribed 
capillary  bronchitis 
about  the  deposit. 

2.  Crepitant,  here  oft- 
en called  crackling,  in- 
dicating a  circumscribed 
pneumonia. 

3.  Rubbing  friction 
sounds,  here  often  called 
crumpling,  indicating  a 
circumscribed  dry  pleu- 
risy. 

4.  Sibilant  rales,  indi- 
cating a  spasm  of  the 
tubes,  or  circumscribed 
bronchitis. 

All  these  rales  derive 
their  significance  from 
being  heard  at  the  apex 
(oftener  the  left). 


VOCAL 
RESONANCE. 


Increased  bron- 
chial whisper. 

Increased  vo- 
cal resonance. 

Remember  the 
possible  normal  dis- 
parity. 


PALPATION. 


KEMABKg. 


The  trouble 
is  apt  to  be 
found  about 
equally  d  i  f- 
fused  in  both 
lungs.  This 
disease  is  lia- 
ble to  be  con- 
founded with 
typhoid  fever. 


Increased   vo- 
cal fremitus. 


74 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


DISEASE. 

INSPECTION  AND 
MENSURATION. 

PERCUSSION. 

RESPIRATION. 

Phthisis. 
Second  Stage. 

Some  flattening 
and    deficient    ex- 
pansion of  the  up- 
per part  of   chest 
on  one   side. 
Marked      diminu- 
tion in  size  of  chest 
by  mensuration. 

Dullness,  more  or 
less,  at  upper  part 
of  chest  on  affect- 
ed side. 

Or     tympanitic 
resonance     (c  o  n- 
ducted  from  bron- 
chi, as  there  are  no 
cavities  yet). 

There    may    be 
exaggerated    reso- 
nance from    coex- 
isting lobular  em- 
physema. 

Bronchial  or  bron- 
cho-vesicular or 
weakened  respira- 
tion. Occasionally 
jerking.  (Abnor- 
mal transmission  of 
heart  sounds.) 

Third  Stage. 
(Cavernous.) 

Extra  ordinary 
prominence  of  the 
clavicles  from  the 
falling  in  of  upper 
parts  of  lung,  and 
deficient  expan- 
sion. 

Still  greater  dim- 
inution in  size  of 
chest  by  mensura- 
tion. 

Tympanitic  reso- 
nance  within    cir- 
cumscribed spaces. 
Occasionally 
cracked-metal     or 
amphoric    reso- 
nance. 

Dullness      over 
the  same  space,  if 
the  cavity  is  full  of 
morbid     products, 
as,    e.    g.,    in    the 
morning   before 
copious  expectora- 
tion. 

Cavernous  respi- 
ration, especially  af- 
ter an  abundant  ex- 
pectoration. If  the 
cavities  are  quite 
small,  the  cavern- 
ous respiration  may 
be  drowned  out  by 
the  neighboring 
bronchial  respira- 
tion, or  combined 
with  it,  forming  a 
kind  of  broncho- 
cavernous  respira- 
tion. Rarely  am- 
phoric respiration. 

Dilatation 

OP    THE 

Bronchi. 

(Bronchiectasis.) 

There    may     be 
some  depression  of 
the  chest  over  the 
places  affected. 

Generally    dull- 
ness from  the  con- 
densed   and     con- 
tracted   parenchy- 
ma, and  also  from 
accumulation      of 
mucus. 

Sometimes  tym- 
panitic or  amphor- 
ic resonance,  if  the 
tubes  are  free  from 
morbid  products. 

Bronchial,  if  the 
tubes  are  cylindric- 
al and  unobstruct- 
ed. 

Cavernous  o  r 
amphoric,  if  saccu- 
lar  and  large 
enough. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE   NO.    10,    Continued. 


75 


RALES. 

VOCAL 
RESONANCE. 

PALPATION. 

REMARKS. 

Fine  and  coarse  bub- 
bling rales,  from  soft- 
ened deposit  or  from 
accompanying     c  i  r  - 
cumscribed  bronchitis, 
generally   heard   bet- 
ter in    the    morning 
before  much  expecto- 
ration.    Also   sibilant 
and     sonorous     rales, 
friction     sounds,     and 
crepitant  and  subcrepi- 
tant  rales  may  be  heard. 

Increased 
vocal  reso- 
nance    and 
whisper,   or 
bronchophony 
and  whisper  - 
i n  (j     bro n- 
chop  h  on  y. 
0  c  c  a  s  ion- 
ally      bron- 
choph o  n  i  c 
pectoriloquy. 

Increased    vocal 
fremitus. 

The  accompany- 
ing signs  are  ob- 
served on  the  side 
first  affected,  gen- 
erally at  the  apex. 

By  this  time, 
however,  signs  de- 
noting a  less  ad- 
vanced condition  of 
the  disease  may  be 
heard  at  the  apex 
of  the  other  side. 

Gurgling. 

Very  rarely  metal- 
lic tinkling. 

Sometimes 
caver  nous 
pectoriloquy 
and      whis- 
pering   pec- 
toriloquy. 

Amphoric 
voice    when 
there  is  am- 
phoric    res- 
piration. 

Increased    vocal 
fremitus  when  the 
cavity     is      large, 
superficial,  and  Mas 
free  communication 
with   the   bronchi. 
Sometimes    gur- 
gling    fremitus. 
When  the   disease 
exists     principally 
in    one  lung,    the 
shrinking    of    this 
lung  sometimes 
drags  the  heart  out 
of     place.    Pulsa- 
tion   detected    by 
palpation. 

These  cavernous 
signs  (to  be  sought 
for  especially  in  the 
upper  part  of  the 
lung)  often  have 
in  their  vicinity 
many  of  the  signs 
of  solidification  al- 
ready mentioned. 

Bubbling  rales  from 
mucus       in      dilated 
tubes ;  sometimes  even 
gurgling,   if  there   is 
considerable      dilata- 
tion. 

Increased 
vocal    reso- 
nance    and 
bronchoph  - 
ony. 

Sometimes 
pectoril- 
oquy. 

Increased   vocal 
fremitus. 

Usually  affects 
many  bronchi,  and 
occurs  in  both 
lungs.  Most  com- 
mon in  the  lower 
lobes  and  the  mid- 
dle lobe  of  the  right 
lung.  Follows 
bronchitis,  collapse 
of  pulmonary  lob- 
ules, pleurisy,  and 
pneumonia,  espe- 
cially interstitial 
pneumonia.  The 
dilatation  may  be 
of  three  varieties,  — 
cylindrical,  f  u  s  i- 
form,  or  saccular. 

76 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  10,  Continued. 


DISEASE. 

inspection  and 
mensuration. 

PERCUSSION. 

RESPIRATION. 

Carcinoma 

of 

Lung. 

Diminished   costal 
motion.      Flattening 
and    contraction    of 
the  affected  side  (if 
infiltrated). 

Or  the  growth  may 
be  so  great  (perhaps 
four  or  five  pounds) 
as  to  enlarge  the  side. 

Effacement  of   in- 
tercostal depressions, 
if  pleuritic    effusion 
ensue. 

Dullness,    often 
extending   beyond 
the    median    line, 
with  increased  re- 
sistance, uniformly 
extending    over  a 
part  or  the  whole 
of  a  lung,  if  infil- 
trated,   but    scat- 
tered, if  there  are 
nodules      large 
enough  to  produce 
dullness. 

Bronchial  or 
feeble  or  sup- 
pressed. (Sup- 
pressed by  press- 
ure of  cancerous 
deposit  on  a  large 
bronchus.) 

If  only  one 
lung  is  affected, 
exaggerated  res- 
piration over 
the  healthy  lung. 

Intra- 
thoracic 
Tumors. 

(Especially  aneu- 
rism.) 

/ 

There    may  be    a 
bulging  or  even  per- 
foration  of  the   ribs 
and    sternum,     with 
diminished     respira- 
tory movements. 

Enlargement       of 
chest  not  as  uniform 
as  when  enlarged  by 
liquid.   Distention  of 
superficial      thoracic 
veins  ;  or  of  those  of 
one    or    both   upper 
extremities      with 
oedema ;  or  of  those  of 
one  or  both  sides  of 
the  neck  (significant 
if  there  is  no  tricus- 
pid  regurgitation  or 
dilatation  of  the  right 
heart). 

Local      pulsation, 
synchronous    with 
heart's  systole,  some- 
times visible  in  aneu- 
rism. 

There    may    be 
dullness     or    flat- 
ness over  the  tu- 
rn o  r     (and    over 
pleuritic     effusion 
or  compressed  lung 
if    they     coexist). 
The  dullness  over 
an     aneurism     or 
mediastinal  tumor 
always  extends  up- 
ivards   and  to  the 
right  or  left;     in 
aneurisms       espe- 
cially to  the  right. 
There  must  not  be 
too  forcible  percus- 
sion over  aneurism. 

Over  the  tumor 
weakened  or  sup- 
pressed from 
pressure,  and 
bronchial  over 
compressed  lung, 
if  there  be  any. 

OF  DISEASES  OF  THE  LUNGS. 
TABLE  NO.  10,   Continued. 


77 


RALES. 

VOCAL 
RESONANCE. 

PALPATION. 

REMARKS. 

Bubbling  rales, 
if  softening  takes 
place,  or  if  there 
is   secondary 
bronchitis. 

Increased 
vocal     reso- 
nance    and 
bronchoph  - 
ony. 

Vocal  fremitus  at 
first   increased,  then 
diminished. 

A   rare  disease. 

Usually  encepha- 
loid  and  associated 
with  mediastinal  can- 
cer. There  are  two 
varieties  :  — 

1.  Secondary  nodu- 
lar deposit,  of tener  af- 
fecting both  lungs,  the 
nodules  varying  in 
size  from  a  pea  to  an 
orange.  If  few,  small, 
and  scattered,  they 
may  not  give  rise  to 
any  physical  signs. 

2.  Primary  ivjiltra- 
tion  into  the  air-cells, 
usually  affecting  one 
lung.  Pleuritic  effu- 
sion often  coexists. 
Softening  and  exca- 
vation may  take 
place. 

There  may  be 
bubbling  rales 
from     secondary 
bronchitis,  or 
from      softening 
if  the    tumor  is 
cancerous. 

There  is  often, 
but  not    always, 
heard  over  an  an- 
eurism a  systolic 
murmur,   soft    or 
harsh  or  roaring, 
and    of  variable 
intensity.     Rare- 
ly there  may  be 
heard  also  a  dias- 
t  o  1  i  c  murmur, 
caused     by     the 
passage  of  blood 
out  of  the  sac. 

Vocal  res- 
onance   va- 
riable. 
Bronchoph- 
ony   over 
c  o  mpressed 
lung  tissue, 
if    there  be 
any. 

Vocal  fremitus  di- 
minished     or      sup- 
pressed  over  tumor. 
Increased  over  com- 
pressed lung  and  pri- 
mary bronchi. 

Heart      pulsations 
may  often  be  felt  out 
of    place    in    conse- 
quence of  the  press- 
ure.  The  arteries  on 
one  side  may  be  com- 
pressed more  than  on 
the  other.     Over  an- 
eurism an  impulse  is 
felt  synchronous  with 
the    heart's    systole, 
sometimes     stronger 
even  than  over    the 
heart,      sometimes 
double,  either  throb- 
bing or   undulating. 
Often  a  purring  thrill 
is  felt,  generally  cir- 
cumscribed,       but 
sometimes      diffused 
over  a  large  portion 
of  the  chest. 

These  tumors  are, 
in  the  great  majority 
of  cases,  aneurisms ; 
but  sometimes  are 
cancerous,  fibrous,  or 
fatty  tumors,  which 
generally  start  from 
the  mediastinum. 
They  often  exert 
great  pressure  (to 
their  injury,  of 
course)  on  the  heart, 
lungs,  nerves,  or  ves- 
sels, with  character- 
istic symptoms.  Tu- 
mors may  be  on  one 
or  both  sides  of  chest. 
Pleuritic  effusion  may 
result,  also  collapse 
of  pulmonary  lobules 
or  oedema.  A  n  e  u  - 
risms  arise  most  com- 
monly from  the  as- 
cending portion  of 
the  arch  of  the  aorta. 

78 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11. 


The 

Healthy 

Heart. 


AUSCULTATION. 


Pericardi- 
tis. 

First  Stage. 

(Exudation  of 
fibrin.) 


When  heard  over  the  apex,  the 
two  healthy  heart  sounds  may  be 
roughly  represented  by  a  trochee 
with  dots  marking  the  pauses, 
thus  : -^  . .  .  The  first  or  sys- 
tolic is  accented,  long,  booming 
and  of  low  pitch,  and  the  second  or 
diastolic  sound  is  short  and  valvu- 
lar. At  the  base  of  the  heart  the 
two  sounds  may  more  nearly  be  rep- 
resented by  an  iambus  ^.  .  —  .  .  ., 
the  second  sound  being  here  ac- 
cented and  as  long  as,  if  not  longer 
than,  the  first  sound,  and  more  in- 
tense. This  is  because  the  booming 
quality,  caused  by  the  "  element  of 
impulsion "  or  "  muscular  ele- 
ment," is  not  transmitted  so  far 
as  the  valvular  element  of  the  first 
sound. 


percussion. 


A  characteristic  friction  sound, 
often  lasting  a  few  hours  only,  but 
sometimes  for  a  few  days,  pro- 
duced by  the  rubbing  together  of 
the  inflamed  and  roughened  peri- 
cardial surfaces  in  the  systolic  and 
diastolic  movements  of  the  heart. 
It  is  either  single  or  double,  strictly 
accompanying  or  independent  of 
the  heart  sounds,  always  super- 
ficial, and  usually  restricted  to  the 
precordial  space,  —  sometimes 
even  to  a  part  of  it  only.  Heard 
with  the  greatest  intensity  on  the 
left  edge  of  the  sternum  on  a  level 
with  the  fourth  rib.  Quality  graz- 
ing, crumpling,  creaking,  or  rasp- 
ing, and  either  feeble  or  loud.  In- 
tensity increased  by  bending  the 
body  forward  so  that  the  heart  is 
brought  nearer  the  chest  walls. 
Also  increased  by  firm  pressure 
with  the  stethoscope;  also  by  a  full 
inspiration,  the  pericardial  surfaces 
being  forced  nearer  together  by  the 
expanded  lung.  A  single  sound 
may  be  made  double  in  this  way. 


The  space  on  the  surface 
of  the  chest  beneath  which 
the  heart  lies  is  called  the 
prcecordia,  or  precordial 
region.  That  part  of  the 
prsecordia  which  is  uncov- 
ered of  lung  is  called  the  su- 
perficial cardiac  space,  and 
the  rest,  where  lung  tissue 
intervenes  between  the 
heart  and  chest  walls,  is 
called  the  deep  cardiac 
space.  The  boundaries  of 
each  of  these  spaces  must 
be  carefully  memorized. 
They  are  well  shown  on 
Plate  I. 

The  dullness  over  the 
deep  cardiac  space,  though 
distinct,  is  of  course  much 
less  than  that  over  the  su- 
perficial cardiac  space. 


OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11. 


79 


INSPECTION. 

PALPATION. 

REMARKS. 

The     apex     i  m- 
pulse  of  the  healthy 
heart     can     f  r  e- 
quently,  but  not  al- 
ways, be  seen  in  the 
same  place  in  which 
it  is  felt. 

The  healthy  apex  beat  in  the  sit- 
ting or  standing  posture  is  felt  in 
the  fifth  intercostal  space,  but  often 
in   the   fourth  when   lying  on  the 
back.     It    is  felt  over   an  area  an 
inch  in  diameter,  from  half  an  inch 
to  two  inches  to   the   right  of    the 
linea   mammalis    (a  vertical    line 
drawn  through  the  left  nipple),  and 
about  three  inches,  on  an  average, 
to  the  left  of  the  median  line.  When 
lying  on  the  rifjht  side,  the  centre 
of  the  area  is  about  half  an   inch 
nearer  the  sternum,  and  when  lying 
on  the  left  side  it  is  felt  on  the  linea 
mammalis.      In  some   persons   the 
apex  beat  cannot  be  felt  at  all,  espe- 
cially when  lying  on  the  right  side. 
It  is  felt  better  when  on  the  back, 
still  better  when  sitting,  and  best 
of  all  when  on  the  left  side. 

For  purposes  of 
conipari  son,  the 
signs  of  the 
healthy  heart  are 
placed  here. 

A  thorough 
knowledge  of  the 
healthy  heart  is  an 
absolutely  indispen- 
sable prerequisite  to 
an  understanding  of 
the  diseased  organ. 

■ 

Irrit  able    and 
forcible   action    of 
heart. 

Forcible  action  of  heart  and  fric- 
tion fremitus. 

Endocarditis  with 
its  physical  signs 
often  coexists. 
Rheumatic  pericar- 
ditis, which  occurs 
perhaps  once  in 
every  six  cases  of 
rheumatic  fever, 
is  almost  always  ac- 
companied by  endo- 
carditis. 

80 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


Pericar- 
ditis. 

Second 
Stage. 

(Serous  ef- 
fusion.) 


Endo- 
cardi- 
tis. 


AUSCULTATION. 


Friction  sounds  generally  (but 
not  invariably)  disappear  when 
the  effusion  becomes  considera- 
ble ;  often  remaining,  however, 
at  the  base  of  the  heart  near  the 
large  vessels,  and  sometimes  be- 
ing distinctly  heard  all  over  the 
prsecordia,  in  spite  of  the  effu- 
sion, by  bending  the  body  for- 
wards. Heart  sounds,  especially 
the  first,  now  feeble  and  distant, 
or  absent  altogether.  Absence 
of  respiratory  murmur  and  vocal 
resonance  over  the  enlarged  area 
caused  by  the  distention  of  the 
pericardial  sac,  the  distention 
pushing  the  lungs  to  the  right 
and  left. 

During  absorption  the  friction 
sounds  reappear  and  may  last  a 
week  or  more ;  and  the  heart 
sounds  become  more  distinct. 


A  systolic  murmur,  generally 
soft  and  feeble,  due  to  thickening 
or  roughening  of  the  inflamed  en- 
docardium, heard  sometimes  at 
the  aortic  orifice,  but  usually  at 
the  apex.  The  swollen  mitral 
valves  with  shortened  chords  may 
be  slightly  insufficient,  but  usu- 
ally the  murmur  is  mitral  non-re- 
gurgitant,  caused  by  intra-Yentric- 
ular  roughness. 

Auscultation  of  the  heart  should  he 
practiced  at  the  beginning  of  every  case 
of  rheumatic  fever,  to  make  sure  that 
there  is  no  old  valvular  lesion  which 
might  be  mistaken  for  a  recent  endo- 
carditis. If  there  he  an  old  valvular 
murmur,  there  will  be  more  or  less 
cardiac  hypertrophy,  and  the  murmur 
may  be  loud  and  rough. 


PERCUSSION. 


With  large  effusion,  the  area  of 
precordial  dullness  is  greatly  in- 
creased vertically  and  laterally, 
and  in  the  upright  posture  it  be- 
comes pyramidal  in  shape,  corre- 
sponding to  the  form  of  the  dis- 
tended sac,  whose  base  is  near  the 
sixth  intercostal  space,  and  apex 
near  the  sternal  notch,  and  which 
may  extend  laterally  almost  from 
one  nipple  to  the  other. 

In  chronic  pericarditis  with  very 
large  effusion  and  dilatation  of  the 
sac,  the  dullness  or  flatness  may 
extend  nearly  to  the  axillary  and 
infra-axillary  regions  on  each  side. 
The  dullness  from  the  liquid  ex- 
tends below  the  point  of  the  apex 
beat.  The  anterior  portion  of  the 
sac  is  mostly  uncovered  of  lung 
and  in  contact  with  the  chestwalls. 
When  the  patient  lies  down,  the 
lateral  diameter  of  dullness  is  in- 
creased at  the  expense  of  the  ver- 
tical. 

If  the  effusion  is  small,  there  is 
merely  an  increase  in  the  lateral 
diameter  of  dullness  at  the  lower 
portion  of  the  precordial  region 
in  the  upright  posture. 

Gradual  diminution  of  the  area 
of  dullness  as  convalescence  ap- 
proaches. 


OF  DISEASES   OF  THE  HEART.  81 

TABLE   NO.    11,  Continued. 


INSPECTION. 


Arching  forward  of 
the  precordial  region 
(mostly  in  young  peo- 
ple, whose  costal  carti- 
lages are  pliable),  often 
extending  from  the  sec- 
ond to  the  sixth  intercos- 
tal space.  The  effusion, 
if  large,  restrains  the 
respiratory  movem  e  n  t 
on  the  left  side. 


At  first  the  area  of 
the  visible  impulse  of 
the  heart  is  increased, 
but  later  it  is  apt  to  be 
indistinct. 

Irregular  beating. 


PALPATION. 


The  point  of  the  apex 
beat  raised  and  carried 
to  the  left  of  its  normal 
position.  Friction 
fremitus  disappears. 

Apex  beat  feeble,  or 
imperceptible,  if  effu- 
sion is  large. 


At  first  violent  and 
excited  action,  after- 
ward weakened. 


Usually  the  effusion  lasts 
about  a  week  or  ten  days 
in  acute  cases. 

Hydropericardium  has 
physical  si^ns  which  do 
not  materially  differ  from 
those  of  pericarditis,  ex- 
cept that  there  is  no  fric- 
tion sound. 


Occurs  in  the  great  ma- 
jority of  instances  as  a  sec- 
ondary affection  in  the 
course  of  acute  articular 
rheumatism.  It  is  more 
common  than  pericarditis, 
with  which  it  is  often  asso- 
ciated, being  far  oftener 
observed  without  pericar- 
ditis than  the  latter  is  with- 
out it. 

It  may  occur  in  the  es- 
sential and  exanthematous 
fevers,  in  pyemia,  Bright's 
disease,  diphtheria,  etc. 


82 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.  11,  Continued. 


DISEASE. 

auscultation. 

PERCUSSION. 

Hypertrophy 

OF    THE 

Left  Heart. 

First  sound  loud,  dull,  and 
prolonged.      Aortic   second 
sound  exaggerated,  if  there 
are  no  valvular  lesions.  Ab- 
sence or  gi'eat  diminution  of 
vocal  resonance  over  a  larger 
area  than  normal,  showing 
,  an  enlarged  superficial  car- 
diac space.     This  sign  is  es- 
pecially available  in  females 
with   large   breasts,   where 
percussion  is  difficult. 

Extension  of  percussion 
dullness  to  the  left,  and  down- 
wards in  the  direction  of  the 
apex,  especially  the  latter. 
Superficial  cardiac  space  in- 
creased (the  lung  being  pushed 
to  the  left),  and  greater  degree 
of  dullness  over  it  than  in 
health.  This  increase  must 
not  be  confounded  with  that 
produced  by  retraction  of  the 
lung  from  its  own  diseases. 

Hypertrophy 

OF    THE 

Right  Heart. 

First  sound  loud,  dull,  and 
prolonged  (except  in  some 
cases   of   extensive   emphy- 
sema, where  the  edges  of  the 
lungs    by    overlapping    the 
heart    partially  muffle    the 
sound),  heard  with  greatest 
intensity  near  the  ensiform 
cartilage. 

Exaggeration  of  the  pul- 
monary second  sound,  espe- 
cially if  there  is  obstruction 
to   the    pulmonary   circula- 
tion.    Auscultation  of  the 
voice    available    as    in  the 
preceding. 

Some  extension  of  dullness 
to  tire  right  of  the  normal 
dullness,  but  not  in  propor- 
tion to  the  amount  of  the  en- 
largement of  the  heart,  the 
increased  area  of  dullness 
being  mostly  to  the  left. 

There  is  often  dullness  over 
the  second  and  third  right 
cartilages  near  the  sternum, 
owing  to  the  enlarged  right 
auricle. 

OF  DISEASES  OF   THE  HEART. 
TABLE   NO.  11,   Continued. 


83 


INSPECTION. 

TALPATION. 

REMARKS. 

Increased  area  of  visi- 
ble  impulse,   extending 
over  several  intercostal 
spaces    and    sometimes 
over  the  whole  of  the 
praecordia.     In  children 
there  is  often  an  abnor- 
mal   projection    of    the 
precordial  region.  Apex 
beat  seen  to  be  lower  and 
farther  to  the  left  than 
normal.     If  it  cannot  be 
seen,  it  can   almost   al- 
ways be  felt.     If  not,  it 
can  be  located  by  auscul- 
tation. 

Apex  beat  is  felt  in 
the       sixth,      seventh, 
eighth,  or  even  ninth  in- 
tercostal space,  and  to 
the    left    of    the    linea 
mammalis,     the    down- 
ward displacement  being 
especially    marked.     It 
is  powerful  and  distinct, 
though  sluggish. 

A    powerful    heaving 
movement  is  felt  all  over 
the  praecordia. 

When  the  whole  heart  is 
hypertrophied,  the  physical 
signs  of  left  and  right  side 
hypertrophy  are  combined 
in  varied  proportions. 

In  the  great  majority  of 
cases  of  cardiac  hypertro- 
phy, valvular  lesions  coex- 
ist, and  are  accompanied  by 
their  respective  murmurs. 
When  there  are  no  valvular 
lesions,  chronic  Bright's  dis- 
ease is  the  most  common 
cause  of  left  heart  hyper- 
trophy. 

Increased  area  of  im- 
pulse and  abnormal  pro- 
jection as  above. 

Strong   epigastric   im- 
pulse seen  as  well  as  felt, 
often  shaking  the  lower 
part  of  the  sternum  and 
extending  more  or  less 
over  the  liver. 

Apex  beat  is  felt  far- 
ther to  the  left  generally 
than  in  left  side  hyper- 
trophy    (perhaps    one, 
two,  or  even  three  inches 
to  the  left  of  the  nip- 
ple), but  not  so  far  down, 
the  lower  border  of  the 
heart  being  almost  hori- 
zontal. 

Apex  beat  sometimes 
feeble  on  account  of  the 
apex  becoming  rounded 
or  blunted.     Even  then 
there  will  be  strong  im- 
pulse in  the  intercostal 
spaces  above  the  apex. 

Powerful     heaving 
movement  all  over  the 
praecordia. 

Pulmonary  emphysema 
is  the  most  common  cause 
of  right  heart  hypertrophy, 
when  there  are  no  valvular 
lesions. 

If  the  apex  cannot  be 
felt,  its  location  can  be  as- 
certained by  finding  by  aus- 
cultation the  spot  where  the 
first  sound  has  the  greatest 
intensity. 

84' 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.  11,  Continued. 


Dilatation  of 
the  Heart. 


AUSCULTATION. 


First  sound  short,  feeble, 
and  valvular,  lacking  par- 
tially or  entirely  the  element 
of  impulsion  or  muscular 
element,  thus  resembling 
the  second  sound.  Second 
sound  often  inaudible  at  the 
apex.  Irregular  pauses,  or 
intermissions  of  the  beat, 
especially  on  exertion.  If 
a  murmur  has  previously 
existed,  its  rhythm  may 
become  lost,  and  it  may 
become  impossible  to  say 
whether  it  is  synchronous 
with  the  first  or  second 
sound.  This  is  called  asys- 
tolism. 

Respiratory  murmur  di- 
minished in  intensity  over 
the  upper  part  of  the  left 
lung. 


PERCUSSION. 


Area  of  dullness  is  in- 
creased in  every  direction, 
especially  laterally,  the  trans- 
verse diameter  greatly  ex- 
ceeding the  vertical.  The 
shape  of  the  dullness  is  oval 
or  square  instead  of  the  nor- 
mal triangular  dullness. 

An  upward  and  lateral  in- 
crease of  dullness  at  the  base 
of  the  enlarged  heart  indi- 
cates dilated  auricles. 


OF  DISEASES  OF   THE  HEART. 
TABLE   NO.  11,  Continued. 


85 


INSPECTION. 


The  area  of  visible 
impulse  is  increased,  but 
it  is  indistinct. 

Iu  persons  with  thin 
chest  walls  an  undulat- 
ing motion  over  the 
prsecordia  may  be  visi- 
ble. 


PALPATION. 


Feeble  cardiac  im- 
pulse. No  heaving  move- 
ment, but  weak  undu- 
lating motion  over  the 
whole  prcecordia. 

A  queer  sensation  of 
rolling  over,  a  kind  of 
diffused  tumble  against 
the  chest  walls  followed 
by  a  pause. 

Apex  beat  not  so  low 
as  in  hypertrophy. 


In  a  great  many  cases 
hypertrophy  and  dilatation 
are  combined  in  varied  pro- 
portions, so  that  we  have 
enlargement  with  predom- 
inating hypertrophy  or  en- 
largement with  predomi- 
nating dilatation.  Hyper- 
trophy precedes  dilatation 
with  rare  exceptions ;  if  the 
enlargement  be  very  great, 
dilatation  predominates. 

From  the  accompanying 
physical  signs  under  hyper- 
trophy and  dilatation,  it  can 
generally  be  determined 
which predo minates,  to 
what  extent,  and  which  side 
(if  either)  is  more  particu- 
larly affected. 

Hypertrophy  is  more,  es- 
pecially the  characteristic 
of  the  left  ventricle,  and 
dilatation  of  the  right  ven- 
tricle, although  either  may 
affect  both. 


86 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


VALVULAE 
LESIONS. 

/.  Left  Heart. 


Aortic  Ob- 
struction. 

(Stenosia.) 

[2-] 

Numbers  in 
brackets  repre- 
sent order  of 
frequency  ac- 
cording  to 
TValshe. 


AUSCULTATION. 


Rhythm  of 
Murmur. 


Systolic. 


Maximum  Inten- 
sity of  Murmur. 


Second  right 
intercostal 
space,  near  the 
sternum. 

Exceptionally 
second  left  inter- 
costal space  near 
the  sternum. 


Murmur 
also  heard. 


Over  the  ca- 
rotids, more  or 
less  over  the 
body  of  the 
heart,  some- 
times in  the 
interscapul  a  r 
space  near  the 
spinous  ridge 
of  the  scapula, 
feebly  or  not 
at  all  at  the 
apex. 

Transmitted 
better  upwards 
than  down- 
wards. 


Other  things  to 
be  noticed. 


Murmur  gen- 
erally soft,  but 
may  be  rough 
or  musical,  and 
it  always  more 
or  less  ob- 
scures the  first 
sound  of  the 
heart. 

Aortic  second 
sound  weak- 
ened and  in- 
distinct in  pro- 
portion to  the 
amount  of  ob- 
struction. 

Aortic  re- 
gurgitation is 
often  asso- 
ciated, when 
there  is  a  dis- 
tinct double 
murmur  heard 
over  a 
space. 


OF  DISEASES   OF   THE  HEART.  87 

TABLE    NO.   11,   Continued. 


PERCUSSION. 


Hypertrophy  of 
the  left  ventricle 
is  induced  after 
the  obstruction 
has  existed  for  a 
while,  and  there- 
fore is  found  in 
the  majority  of 
cases  which  come 
under  observa- 
tion. 

Finally  dilata- 
tion may  ensue. 

See  percussion 
signs  under  Left 
Heart  Hyper- 
trophy and  Dila- 
tation. 


INSPECTION.  PALPATION 


See  Left 
Heart  Hyper- 
trophy and 
Dilatation. 


See  Left 
Heart  Hyper- 
trophy and 
Dilatation. 


Aortic  obstruction  is  a 
very  common  form  of 
heart  disease.  Besides 
the  very  frequent  associa- 
tion of  aortic  regurgita- 
tion, it  may  induce  after 
awhile  mitral  insufficiency. 
It  is  most  frequently  met 
with  in  middle  or  ad- 
vanced life. 

It  has  to  be  diagnostica- 
ted from  an  inorganic  aortic 
murmur  which  is  not  un- 
common in  anaemia.  This 
and  the  other  inorganic 
murmur — the  pulmonic 
—  are  always  systolic. 

The  distinguishing  feat- 
ures of  the  inorganic  aortic 
murmur  are  :  — 

Uniformly  soft  and  fee- 
ble, not  constant,  not  pro- 
ductive of  cardiac  enlarge- 
ment, accompanied  by  a 
continuous  hum  in  jugular 
veins  (with  sometimes  a 
musical  intonation),  called 
"  bruit  de  diable,"  which  is 
suspended  by  pressure 
over  the  veins  with  the  fin- 
ger, and  by  symptoms  of 
anaemia  (which  is  more 
common  among  females 
than  males) ;  the  aortic 
second  sound  as  intense  as 
normal,  and  never  accom- 
panied by  aortic  regurgi- 
tation. 

Sometimes  there  may  be 
an  innocuous  murmur,  not 
inorganic  but  produced  by 
mere  roughness  not  suffi- 
cient to  cause  obstruction, 
and  consequently  not  fol- 
lowed by  cardiac  enlarge- 
ment. 


88 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.  11,   Continued, 


AUSCULTATION. 

Rhythm  of 
Murmur. 

Maximum  Inten- 
sity of  Murmur. 

Murmur 
also  heard. 

Other  things 
to  be  noticed. 

Aortic 
Kegurgita- 

TION. 

(Insufficiency.) 

[3.] 

Diastolic. 

Second  right 
intercostal 
space      (or 
fourth  left  cos- 
tal cartilage), 
near  the  ster- 
num. 

Diffused 
over    a    large 
area,    extend- 
ing in  the  di- 
rection of  the 
apex   or  ensi- 
form  cartilage, 
and  heard   at 
the    sides     of 
the  chest  and 
along  the  spine. 

Transmitted 
better     down- 
wards than  up- 
wards. 

Murmur  gen- 
erally soft,  but 
may  be  rough 
or  musical.  It 
replaces  or  im- 
mediately fol- 
lows the  aortic 
second  sound, 
which  is  weak- 
ened or  sup- 
pressed. 

Aortic  ob- 
struction often 
coexists,  when 
there  is  a  dis- 
tinct double 
murmur  heard 
over  a  large 
space. 

Mitral 
Obstruc- 
tion. 

(Stenosis.) 
[4-] 

Presystolic. 

At  or    near 
the  apex. 

Over  the  su- 
perficial    car- 
diac  space 
only. 

Murmur  gen- 
erally rough, 
long,  and  loud, 
sometimes 
called  "blub- 
bering ;  "  b  e- 
ginning  after 
the  second 
sound  and  end- 
i  n  g  abruptly 
with  the  first 
sound. 

Weakened 
aortic  second 
sound,  and  in- 
tensified p  u  1- 
monic  second 
sound,  the  lat- 
ter owing  to 
obstruction  of 
the  pulmonary 
circulation. 

OF  DISEASES   OF  THE  HEART. 
TABLE   NO.  11,  Continued. 


89 


PERCUSSION. 

INSPECTION. 

PALPATION. 

REMARKS. 

Great    hypertrophy 
and  afterwards  dilata- 
tion  of  the   left  ven- 
tricle    are     induced. 
Therefore  in  the  early 
part    of    the   disease, 
the   percussion    signs 
of    the    former,   and 
later    those    of    both 
combined,     will      be 
found  ;  finally,  if  the 
patient      lives      long 
enough,  only  those  of 
dilatation. 

See    Left 
Heart     Hy- 
pertr  o  p  h  y 
and    Dilata- 
tion,     espe- 
cially      the 
latter. 

See    Left 
Heart     Hy- 
pert  roph  y 
and   Dilata- 
tion,     espe- 
cially    the 
latter. 

Strong, 
jerking,   ar- 
terial pulsa- 
tion felt  in 
supe  rficial 
arteries    all 
over     the 
body. 

Aortic  regurgitation  is 
more  apt  to  induce  mitral 
insufficiency  than  aortic 
obstruction  is. 

In  such  cases  there  may 
coexist  two,  three,  or  even 
all  four  of  the  murmurs 
of  the  left  side  of  the 
heart. 

There  is  generally  nei- 
ther dropsy  nor  dyspnoea 
in  aortic  diseases,  unless 
mitral  regurgitation  coex- 
ists. 

Dilatation,  and  oft- 
en    hypertrophy,     of 
the  left  auricle  is  first 
produced,  followed  by 
hypertrophy    of    the 
right  ventricle  to  over- 
come the   pulmonary 
obstruction ;  next,  dil- 
atation of   the   right 
ventricle;  next,  dila- 
tation of  the  right  au- 
ricle. 

Finally,  not  often, 
but  exceptionally,  hy- 
pertrophy   or   dilata- 
tion of  the  left  ven- 
tricle. 

Percussion  signs  ac- 
cordingly. 

See  Right 
Heart     Hy- 
pertr  o  p  h  y 
and    Dilata- 
tion,    espe- 
cially      the 
latter. 

See  Right 
Heart     Hy- 
pert  r  o  p  h  y 
and    Dilata- 
tion,     espe- 
cially      the 
latter. 

Dis  tin  ct 
purring  thrill 
over     the 
apex,      pre- 
systolic    in 
time. 

Mitral  obstruction  is 
comparatively  a  rare  dis- 
ease, and,  when  met  with, 
is  oftener  found  in  con- 
nection with  mitral  regur- 
gitation than  alone.  Still 
it  may  exist  without  re- 
gurgitation. It  is  possible 
to  have  mitral  obstruction 
without  a  murmur,  if  the 
curtains  are  not  adherent 
at  their  sides ;  and  on  the 
other  hand,  Flint  says  that 
there  may  be,  rarely,  a 
mitral  direct  murmur  with- 
out obstruction  when  there 
is  also  free  aortic  regurgi- 
tation. 

The  orifice  is  sometimes 
too  small  to  admit  the  end 
of  the  little  finger,  whereas 
in  health  three  fingers  can 
be  passed  through  it. 

There  cannot  be  much 
mitral  obstruction  or  re- 
gurgitation so  long  as  the 
aortic  and  pulmonic  second 
sounds  preserve  their  nor- 
mal relative  intensity. 

90 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


auscultation. 

DISEASE. 

Rhythm  of 
Murmur. 

Maximum  In- 
tensity of 
Murmur. 

Murmur 
also  heard. 

Other  things 
to  be  noticed. 

Systolic. 

At  or  near 

Over   the 

Murmur  general- 

the apex. 

supe  rficial 
cardiac 
space ;    and 
unless     too 
feeble,  in  the 
left     axilla 
and  behind, 
near    the 
lower  angle 
of  the    left 
scapula. 

ly  soft,  but  some- 
times rough  or  mu- 
sical. 

Aortic  second 
sound  weakened, 
but  pulmonic  sec- 
ond sound  (heard 
in  the  second  left 
intercostal  space) 
often  intensified. 

Where  mitral  ste- 
nosis and  regurgi- 
tation coexist,  there 
will  be  one  continu- 
ous murmur,  made 
up  of  two  elements, 
presystolic  and  sys- 

Mitral 

tolic  ;    the   first   of 

Regurgita- 

which  will  not    be 

tion. 

conveyed  to  the  left 
and  back.    Besides, 

(Insufficiency.) 

they  almost  always 
differ  in  pitch  and 

[1-] 

• 

quality. 

OF  DISEASES   OF   THE  HEART 
TABLE   NO.  11,  Continued. 


91 


PERCUSSION. 


INSPECTION. 


The  same 
changes  take 
place  as  in  the 
preceding ;  and 
besides,  there  is 
always  more  or 
less  hypertrophy 
or  dilatation  of 
the  left  ventricle. 
Percussion 
dullness  increased 
in  every  direction. 


Area  of  vis- 
ible impulse  in- 
creased. 


PALPATION. 


Impulse  forci- 
ble or  diffused 
according  to  the 
proportion  of  hy- 
pertrophy or  dil- 
atation. 

Apex  beat  far- 
ther to  the  left 
than  normal. 

If  hypertrophy 
predominates,  it 
will  be  lower 
than  if  dilatation 
predominates. 

Pulse  variable 
in  volume,  and  in 
the  later  stages 
also  irregular  in 
time. 


REMARKS. 


The  commonest  of 
all  valvular  diseases, 
especially  among  the' 
young.  It  often  ex- 
ists alone,  but  may 
have  mitral  obstruc- 
tion associated  with  it. 
It  is  almost  invaria- 
bly attended  by  a 
murmur,  but  a  mitral 
systolic  non-regurgitant 
murmur  may  be  pro- 
duced by  simple 
roughening,  c  a  1  c  a- 
reous  deposit,  etc., 
without  insufficiency 
of  the  valve.  The 
signs  which  especially 
distinguish  the  regur- 
gitant from  the  non-re- 
gurgitant murmur  are 
the  strong  pulmonary 
second  sound,  the 
weak  aortic  second 
sound  existing  even 
with  hypertrophy  of 
the  left  ventricle,  the 
diffusion  of  the  mur- 
mur to  the  left  side 
and  to  the  back,  and, 
after  the  disease  has 
made  some  progress, 
the  symptoms  of  pul- 
monary congestion. 

D  y  s  p  n  03  a  and 
dropsy  are  prominent 
symptoms  of  mitral 
obstruction  and  re- 
gurgitation. 

Tricuspid  regurgi- 
tation is  often  found 
as  a  secondary  affec- 
tion in  connection 
with  mitral  disease. 


92 


THE  PHYSICAL  DIAGNOSIS 
TABLE  NO.  11,  Continued. 


auscultation. 

DISEASE. 

Rhythm   of 
Murmur. 

Maximum  In- 
tensity of 
Murmur. 

Murmur  also 
heard. 

Other  things  to 
be  noticed. 

Systolic. 

Second  or 

Propagated 

Second  pulmonic 

third  left  in- 

upwards  for 

sound   impaired  in 

tercostal 

a  short  dis- 

intensity. 

space,   near 

t  a  n  c  e    to- 

Murmur    super- 

the sternum. 

wards      the 
left  clavicle, 
but  not  over 
the  aorta  or 
carotids. 
Remember 
that   excep- 

ficial and  may  be 
quite  intense.  Must 
be  diagnosticated 
from  the  inorganic 
pulmonic  murmur, 
which  is  far  more 
common    than    the 

II.  Right 

tionally    an 

organic,      either 

Heart. 

aortic      ob- 
structive 
murmur 

alone  or  with  the 
other  inorganic 
m  u  r  m  u  r — t  he 

Pulmonic 

may  be  heard 

aortic  direct. 

Obstruc- 

with great- 

Inorganic     mur- 

tion. 

est  intensity 
at  the second 

murs  are  always 
systolic,  and  almost 

(Stenosis.) 

or  third  left 
i  nt  ercostal 

never  occur  except- 
ing at  the  aortic  and 

[6.] 

space.    The 
frequency  of 
the      aortic 
murmur 
and  its  other 
charact  e  r  s 
will    gener- 
ally   suffice 
for  a  diag- 
nosis. 

pulmonic  orifices. 

The  inorganic 
murmur  is  soft  and 
feeble,  with  normal 
heart  sounds  and 
no  enlargement,  not 
constant,  occurs  in 
anaemic  persons,  es- 
pecially young  fe- 
males, and  is  ac- 
companied by  the 
bruit  de  diable. 

Diastolic. 

Second  or 

Propagated 

Pulmonic  second 

third  left  in- 

downwar d  s 

sound   impaired  in 

ter  costal 

towards  the 

intensity. 

Pulmonic 

space,    near 

ensiform 

This  murmur,  if 

Regurgita- 

the sternum. 

cartilage. 

it  were  more  com- 

tion. 

mon,  might  easily 
be  confounded  with 

(Insufficiency.) 

an  aortic  regurgi- 
tant murmur,  when 

[?•] 

the  pulmonary  di- 
rect murmur  did 
not  co-exist. 

OF  DISEASES  OF  THE  HEART. 
TABLE  NO.  11,  Continued. 


93 


PERCUSSION. 

INSPECTION. 

PALPATION. 

REMARKS. 

Hyper  trophy 

See     Hyper- 

See    Hyper- 

Valvular diseases  of 

and  dilatation  of 

trophy  and  Dil- 

trophy and  Dil- 

the  right   heart,   with 

the  right  ventri- 

atation   of   the 

atation    of   the 

the    exception  of  tri- 

cle are  produced. 

Right  Ventricle. 

Right  Ventricle. 

cuspid    regurgitation, 

Percussion 

are  so   infrequent   as 

signs  accordingly. 

to  be  almost  unheard 
of ;  so  much  so,  that 
when  the  unqualified 
term  "  valvular  dis- 
ease "  is  used,  the  left 
heart  is  always  meant. 

Wheu  right-heart 
lesions  exist,  they  are 
usually,  but  not  inva- 
riably, associated  with 
left-heart  lesions,  un- 
less they  are  congen- 
ital. 

Contrary  to  the  rule 
which  prevails  after 
birth,  the  right  heart 
is  more  commonly  af- 
fected in  prajnatal  life 
than  the  left. 

Theoretically, 

See     Hyper- 

See    Hyper- 

Pulmonic   regurgi- 

hypertrophy and 

trophy  and  Dil- 

trophy and  Dil- 

tation   is    exceedingly 

dilatation  of  the 

atation   of    the 

atation    of    the 

rare,    even    more    so 

right       ventricle 

Right  Ventricle. 

Right  Ventricle. 

than      pulmonic    ob- 

are produced. 

struction.       Conse- 

Percussion 

quently,  the  annexed 

signs  accordingly. 

physical  signs  of  it 
are,  to  a  great  extent, 
theoretical. 

Tricuspid  insuffi- 
ciency may  follow 
pulmonic  obstruction 
or  regurgitation. 

94 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.   11,  Continued. 


AUSCULTATION. 

Rhythm   of 
Murmur. 

Maximum  In- 
tensity of  Mur- 
mur. 

Murmur  also 
heard. 

Other  things  to  be 
noticed. 

Tricuspid 

Presystolic. 

At    lower 

Obstruction. 

part  of  ensi- 
form     carti- 

(Stenosis.) 

lage. 

[8.] 

Systolic. 

At   lower 

Generally 

A  murmur  is  not 

part  of  ensi- 

limited    to 

present   in    many 

form    carti- 

the  superfi- 

cases of  actual  tri- 

lage. 

cial  cardiac 
space. 

cuspid  regurg  i  t  a- 
tion,    even    when 

Tricuspid 

If    trans- 

there   is  a  definite 

Regurgita- 

mitt ed  at 

valvular     lesion. 

tion. 

all,  it  is  to 
the  right. 

Rarely,  if  ever, 
rough. 

(Insufficiency.) 

Pulmonic  second 
sound  diminished  in 

[5.] 

intensity.  Mitral 
or  aortic  murmurs, 
or  horh,  often  coex- 
ist, differing  in  pitch 
and  quality. 

OF  DISEASES  OF  THE  HEART.  95 

TABLE  NO.   11,   Continued. 


PERCUSSION. 


Theoretically, 
hypertrophy  and 
dilatation  of  the 
right  auricle  are 
first  produced. 


First  the  right 
auricle  is  dilated, 
then  the  right 
ventricle  is  hy- 
pertrophied  and 
dilated.  Then 
comes  enlarge- 
ment of  the  left 
ventricle  on  ac- 
count of  its  in- 
creased work. 

Per  c  u  s  s  i  o  n 
signs  accord- 
ingly- 


INSPECTION. 


Jugular  pul- 
sation, synchro- 
nous with  the 
heart's  systole, — 
a  characteristic 
sign  of  tricuspid 
regurgi  tati  on, 
unless  the  right 
ventricle  be  very 
weak  from  dila- 
tation. 

Larger  area  of 
visible  impulse 
than  with  any 
other  valv  u  1  a  r 
lesion. 


PALPATION. 


Indistinct  apex 
beat  unless  there 
is  eonsidera  b  1  e 
hypertrophy  o  f 
the  left  ventricle. 

Distinct  e  p  i- 
gastric  pulsa- 
tion. 


The  rarest  of  all. 


Primary  tricuspid 
regurgitation  is  very 
rare;  but  secondary 
to  mitral  stenosis  or 
regurgitation,  it  is 
not  uncommon. 

It  not  infrequently 
exists  in  cases  where 
there  is  no  definite  le- 
sion of  the  valve,  but 
where,  on  account  of 
enlargement  of  the 
right  heart  from  mit- 
ral disease,  the  tricus- 
pid orifice  is  enlarged 
without  a  proportion- 
ate enlargement  of 
the  valve. 


96 


THE  PHYSICAL  DIAGNOSIS 
TABLE   NO.  11,  Continued. 


Fatty    Degen- 
eration of  the 
Heakt. 


Cardiac  Neuro- 
ses. 

(Nervous    or    func- 
tional disorders  of 
the  heart.) 


auscultation. 


Both  heart  sounds  are  per- 
manently weakened,  especially 
the  first.  The  second  sound 
over  the  apex  is  clearer  and 
louder  than  the  first.  First 
sound  often  absent.  When 
present,  it  is  short  and  valvu- 
lar, the  muscular  element  or 
element  of  impulsion  being 
greatly  impaired.  This  con- 
dition is  persistent,  not  tempo- 
rary; and  several  examina- 
tions must  be  made  before  de- 
ciding on  the  diagnosis. 


Heart  sounds  healthy  in 
quality,  but  intensified,  clearer, 
and  more  abrupt  than  normal. 
Occasionally  the  first  sound  is 
metallic,  and  either  may  be  re- 
duplicated. 

An  inorganic  ansemic  mur- 
mur is  sometimes  heard  at  the 
base  of  the  heart.  It  is  systolic, 
either  aortic  or  pulmonic  or 
both,  soft  and  feeble,  often 
propagated  into  the  carotids, 
and  accompanied  by  a  hum  in 
the  veins  of  the  neck. 


percussion. 


Normal  area  of  dullness 
as  a  rule. 

Sometimes  a  dilated  or 
hypertrophied  heart  un- 
dergoes fatty  degenera- 
tion, when,  of  course,  its 
increased  area  of  dullness 
will  remain. 


Percussion  dullness  nor- 
mal. 

As  a  mere  coincidence, 
functional  disease  may  ex- 
ist in  a  hypertro  p  h  i  e  d 
heart. 


OF  DISEASES   OF   THE  HEART. 
TABLE   NO.   11,  Continued. 


97 


INSPECTION. 

PALPATION. 

REMARKS. 

No  visible  im- 
pulse as  a  rule, 
even  in  thin  per- 
sons. 

If  there  is  any, 
it   is   very   indis- 
tinct. 

Very  little  or  no  apex 
beat  can  be  felt.     If  felt 
it  is  generally  in  its  nor- 
mal position,  and  is  irreg- 
ular or  intermittent. 

If    a  hypertr  o  p  h  i  e  d 
heart  becomes  fatty,  there 
is  a  tumbling,  rolling  mo- 
tion. 

Valvular  lesions  may  co-exist. 
The   diagnosis   of    fatty   de- 
generation of  a  hypertrophied 
heart  is  very  difficult. 

Increased  area 
of    visi b  1  e    im- 
pulse, which  may 
be  seen  to  be  ir- 
regular and    in- 
termit tent     at 
times. 

Apex  beat  in  normal  po- 
sition. 

Increased  action,   not 
power.    Beat  abrupt  and 
brief.      A  violent    blow, 
not  a  powerful  heaving. 

Sometimes    impulse 
weaker  than  natural. 

The  physical  signs  are  both 
negative  and   positive,  —  nega- 
tive in   excluding   all    organic 
disease,  and   positive   in   show- 
ing the   healthy   size,  position, 
and  sounds  of  the  heart. 

Patients  with  functional  dis- 
ease complain  much    more   of 
heart  symptoms  than  those  with 
organic  disease.    Inorganic  pal- 
pitation is  increased  by  seden- 
tary life,  organic  by  exercise. 

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